FCPS Golden Files Papers

golden files fcps

This post contains all “FCPS Golden files” papers.

Some questions related to “FCPS Golden Files” are given at the end of this post (MUST READ)

Golden file 1:

https://www.facebook.com/groups/FcpsPretestSeries/369436393472865/

Golden file 2:

https://www.facebook.com/groups/FcpsPretestSeries/369462306803607/

Golden file 3:

https://www.facebook.com/groups/FcpsPretestSeries/369462406803597/

Golden file 4:

https://www.facebook.com/groups/FcpsPretestSeries/369460140137157/

Errata of golden file 3:

https://www.facebook.com/groups/FcpsPretestSeries/368436013572903/

NOTE: You will have to install “zip opener” to open golden file 4. To open all files, you will need “PDF reader”.

Question: What are FCPS Golden Files?
Answer: These are a collection of most recent papers of FCPS part 1 exam.

Question: Do these papers contain mistakes in answers?

Answer: Unfortunately, these papers are full of mistakes. You will need to correct the keys while doing these papers.

Question: Is there any alternative to “FCPS Golden Files“?
Answer: Fortunately, yes. “FCPS Pretest Series” contain all “FCPS Golden Files” papers, with correct keys, explanations, and arranged chapter-wise.

Question: Do I need to do “FCPS Golden Files” after doing “FCPS Pretest Series” books?
Answer: No, FCPS Pretest Series”” books are enough to cover all golden files.

Question: Do I need to do other MCQs books after doing “FCPS Pretest Series” books?

Answer: No, “FCPS Pretest Series” books have enough collection to cover all most recent MCQs.

Question: Are keys of “FCPS Pretest Series” books reliable?
Answer: Yes, the keys of these books are cross checked multiple times with standard books. You are advised not to change keys of these books unless you have an authentic reference.

Question: Is there any errata available for “FCPS Pretest Series” books?
Answer: No. As mentioned before, these books are reliable and does not need any key. You can study them with the satisfaction that all keys are correct.

Question: How can I purchase “FCPS Pretest Series” books?
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Aortic Stenosis

aortic stenosis

Aortic Stenosis

 

Etiology

 

  • Overall, most common cause Calcification

 

(1) Calcification (normal ageing)

 

  • Most common cause in older patients > 65 years

 

(2) Bicuspid aortic valve

 

  • Most common cause in younger patients < 65 years

  • Normal aortic valve is tricuspid (the only bicuspid valve is mitral valve); bicuspid aortic valve may be stenotic due to cusp fusion.

 

(3) William’s syndrome (supravalvular stenosis)

 

  • A congenital fibrous diaphragm is present above the aortic valve.

 

C:\Users\ayyan\Desktop\williams.jpg

 

(4) HOCM (subvalvular stenosis)

 

(5) Rheumatic heart disease

 

  • RHD may result in aortic valve stenosis due to cusp fusion.

 

 

Assessing the severity

 

Severity of AS is assessed by:

 

  • Valve area

  • Pressure gradient across the valve

 

  • Normal valve area = 3 – 4 cm2{cm} ^ {2}

  • Normal valve gradient < 5 mmHg

 

 

Severity of aortic stenosis

Severity valve area (cm2{cm} ^ {2})

Mean gradient (mmHg)

Mild

1.5 - 3

< 25

Moderate

1.0 – 1.5

25 - 50

Severe

< 1.0

> 50

Critical

< 0.7

> 80

 

 

Symptoms

 

The classic triad of AS is:

 

(1) Angina (exertional)

Angina occurs due to 3 reasons:

 

  • Oxygen demand due to LVH

  • Coronary perfusion due to stenosis and C.O

  • In 50% of AS patients above the age of 35 years, angina occurs due to coexisting CAD.

 

(2) SOB (exertional)

 

SOB/orthopnea/PND occurs due to both:

 

  • Systolic failure (dilated ventricles due to high pressure - ​​ dilated cardiomyopathy)

  • Diastolic failure (LVH - Hypertrophic cardiomyopathy)

 

(C) Syncope (on exertion)

 

 

Examination

 

GENERAL PHYSICAL EXAMINATION

 

(1) CAROTID PULSE

 

  • “Low volume” and “slowly rising pulse” called slow rising pulse.

 

C:\Users\ayyan\Desktop\pulse.jpg

(2) PULSE PRESSURE

  • Narrow (because systolic pressure decreases due to C.O

 

PulsePressure=SystolicDiastolic↓ Pulse Pressure= ↓ Systolic -Diastolic

 

C:\Users\ayyan\Desktop\Untitled.jpg

 

  • Vs. aortic regurgitation, in which pulse pressure becomes wide (due to increased cardiac out resulting in increased systolic pressure)

 

(3) JVP

 

Prominent “a” wave – This is due to reduced compliance of right ventricle which is due to:

 

  • Hypertrophy of ventricular septum

  • Pulmonary hypertension

 

“a” WAVE

 

PRODUCED BY

 

a” wave is produced by “atrial contraction” (late ventricular diastole).

 

C:\Users\ayyan\Desktop\JVP.jpg

 

PROMINENT “a” WAVE

 

“a” wave will be prominent whenever atrial pressure increases:

 

  • Pulmonary hypertension ​​ (any disease causing left sided heart failure)

  • Pulmonary stenosis

  • HOCM

  • Tricuspid stenosis

 

All these conditions causes: RV pressure RA pressure Prominent “a” wave

ABSENT “a” WAVE

 

  • Atrial fibrillation

 

 

 

 

 ​​​​ CVS examination

 

PALPATION

 

(1) APEX BEAT

  • Site: Not displaced (The concentric hypertrophy, in contrast to, dilatation, does not produce cardiomegaly)

  • Character: Heaving (forceful – Due to LVH)

 

CONCENTRIC LVH (hypertrophic cardiomyopathy)

 

  • Concentric hypertrophy is a hypertrophic growth of a hollow organ without overall enlargement, in which the walls of the organ are thickened and its capacity or volume is diminished.

  • LV mass” as well as “wall thickness” increases; but wall thickness increases on the inside of ventricular wall; so:

.

 

  • Ventricular cavity size decreases, and

  • Cardiomegaly does not occur (apex beat not displaced)

 

  • The center of the circle remains in the center.

  • It is caused by volume overload (aortic regurgitation, mitral regurgitation, septal defects, pregnancy)

 

C:\Users\ayyan\Desktop\hypertrophy.jpg

 

 

Eccentric LVH (dilated cardiomyopathy)

 

  • LV mass” increases but “wall thickness” remains normal or decreased.

.

 

  • But ventricular cavity size increases, so

  • Cardiomegaly occurs (apex beat displaced)

 

  • The center of circle is in the periphery of the circle.

  • It is caused by pressure overload (aortic stenosis, HOCM, HTN)

 

 

 

Eccentric hypertrophy

Concentric hypertrophy

LV mass

Increased

Increased

LV wall thickness

Normal or decreased

Increased

 

(but on the inside, so no cardiomegaly – Apex beat not displaced)

Cavity

Dilated

 

(Results in cardiomegaly – Displaced apex beat))

Normal

Type of heart failure

Systolic

 

(Dilated cardiomyopathy)

Diastolic

 

(Hypertrophic cardiomyopathy)

 

Added sounds

  • S3 (Increased early diastolic filling into compliant dilated ventricle)

 

  • S4 (Hypertrophy limits diastolic filling)

 

S4

Causes

Increase in left ventricular volume ​​ (and pressure):

 

  • Valvular regurgitations (Aortic regurgitation + Mitral regurgitation

  • Septal defects

  • Pregnancy

Chronic pressure overload

 

  • Aortic stenosis

  • HOCM

  • HTN

 

(2) SYSTOLIC THRILL

  • At aortic area

 

AUSCULTATION

 

HEART SOUNDS

 

(1) S2:

  • Soft”:

 

  • REASON: Calcified aortic valve is immobile A2 is not audible; only P2 is audible Soft S2

  • SEVERE AS: When S2 is not audible, it can be concluded that AS is severe.

  • Reverse splitting of S2:

 

  • REASON: Delayed closure of aortic valve due to AS → P2 occurs earlier than A2 → Reverse splitting of S2

(2) S4:

 

  • Due to LVH

 

MURMUR (EJECTION – SYSTOLIC)

 

Radiation:

 

  • Carotid artery: The ejection systolic murmur of HOCM does not radiate to neck which helps in differentiating it from murmur of AS.

  • Apex: Murmur of MR at apex is “pansystolic” while that of AS is ejection-systolic.

 

C:\Users\ayyan\Desktop\e964ee6d8bd13247e6118bfaa0e7ea79.jpg

 

Maneuvers:

 

  • Valsalva, standing, hand grip: Murmur decreases due to transvalvular flow

  • Squatting, leg raise: Murmur increases due to transvalvular flow

 

Duration:

  • Longer the murmur, severe is aortic stenosis.

 

Intensity:

  • Intensity of murmur typically increases as the disease progresses.

  • However, in very severe aortic stenosis, cardiac output decreases; as a result, the murmur becomes “softer” or “disappears”. Therefore, intensity of murmur is not a good indicator of disease severity.

 

 

Investigations

 

TTE TEE Cardiac catheterization

 

(1) CXR:

  • Normal (concentric hypertrophy – no cardiomegaly)

 

(2) ECG

  • LVH

 

(3) Echo:

 

​​ Echo can determine:

 

  • Valve area

  • Pressure gradient

 

(4) Cardiac catherization

 

Cardiac catherization is indicated in three conditions:

 

  • Measure gradient: Rarely, cardiac catherization is indicated to measure gradient if echocardiography is unable to determine whether severe aortic stenosis is present or not.

 

  • Angina: Cardiac catherization is indicated when it is suspected that the angina of aortic stenosis may be due to coexisting CAD (50% of aortic stenosis patients older than 35 years of age have CAD).

  • AVR: Angiography should be done before AVR, so that CABG, if indicated, can be performed during the procedure of valve replacement.

 

Treatment

 

(1) ASYMPTOMATIC

 

  • Mild to moderate AS: If the patient is asymptomatic, and AS is not severe, just observe the patient is the general rule.

  • Severe AS: AVR is indicated

 

​​ (2) SYMPTOMATIC

 

  • Medical treatment is not effective.

  • Development of any of the three symptoms is indication for AVR.

 

(A) MEDICAL TREATMENT

  • BETA BLOCKERS: Can be used for angina (but may cause hypotension)

  • ACE INHIBITORS, DIGOXIN, NITRATES: Just like HOCM, these drugs are relatively contraindicated.

 

 

 

Drug

Indication

ACE inhibitors

Symptomatic systolic failure

Digoxin

Decreased EF

Nitrates

Angina

 

 

 

 

 

(B) Surgical treatment

 

(i) AVR

C:\Users\ayyan\Desktop\hqdefault.jpg

INDICATIONS:

 

  • Symptomatic patients (any of the three symptoms)

  • Asymptomatic but severe AS (i.e; valvular gradient > 50 mmHg or valve area < 0.7)

  • Patients undergoing CABG or any other heart surgery

 

 

 

 

C:\Users\ayyan\Desktop\Image_201510071501_10068.jpg

 

(II) BALOON VALVULOPLASTY

 

Definition: It is widening of stenotic aortic valve using a balloon catheter inside the valve.

 

INDICATION: Patients with “critical” aortic stenosis who are not fit for AVR.

 

NOTE: Baloon valvuloplasty is not routinely done because “calcified” aortic stenosis does not respond very well to balloon valvuloplasty.

 

 

TAGS: aortic stenosis murmur radiation causes signs symptoms listen murmur location aortic stenosis treatment

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