MDE CVS 2005

1. Jawaban : B. Secundum defect
Alasan : Nelson hlm 1506
2. Jawaban : A. Widely fixed & split S2
Alasan : Nelson hlm 1506
3. Jawaban : D. The ductus arteriosus normally diverts 80% of RV output
Alasan : Lilly hlm 379
4. Jawaban : ???
Alasan : Kemungkinan A,soalnya opsi lain ga mungkin
5. Jawaban : B. VSDs may be associated with coarctation of aorta
Alasan : Nelson hlm 1508
6. Jawaban : ???
Alasan :
7. Jawaban : ???
Alasan :
8. Jawaban : C. TOF
Alasan : Lilly hlm 390-391
9. Jawaban : E. Premature closure of foramen ovale
Alasan : foramen ovale harusnya menutup setelah lahir bukan pada saat prenatal life
10. Jawaban : D. Coarctation of aorta
Alasan :Lilly hlm 389
11. Jawaban : D. TGA
Alasan : Lilly hlm 393
12. Jawaban : A. Atrial septal defect
Alasan : Lilly hlm 380-381
13. Jawaban : B. Hypoplasia of endocardial cushion
Alasan : Lilly hlm 380-381
14. Jawaban : D. The diatal part of 6th aortic arch
Alasan : Moore embryology hlm 361-365
15. Jawaban : A. Aortic regurgitation
Alasan : Lilly hlm 42
16. Jawaban :
Alasan : Most cases of congenital heart disease were thought to be multifactorial and result from a combination of genetic predisposition and environmental stimulus (nelson)
17. Jawaban : D. Arteries
Alasan : stretch receptor ada di aorta dan carotid sinus
18. Jawaban : C. Closure of foramen ovale due to increase pressure at left atrium
Alasan : yang lain kurang tepat
19. Jawaban : B. Period of isovolumic (isometric) contraction
Alasan : guyton hlm 107
20. Jawaban : D. Higher frequency
Alasan : Lilly hlm 32-33

21. d. TOF: aorta overriding, RV hypertrophy, VSD, pulmonary artery stenosis
22. A. berikut statement dari emedicine tentang VSD: “A measurement of LA and left ventricular (LV) diameters provides semiquantitative information about shunt volume. The size of the defect is often expressed in terms of the size of the aortic root. Defects that approximate the size of the aortic root are classified as large, those one third to two thirds of the diameter of the aorta are classified as moderate, and those less than one third of the aortic root diameter are classified as small”,
Pada defect lain, pada pemeriksaan defect, tidak ditemukan hubungan dengan aorta.
23. D. pada VSD terjadi shifting left to right  peningkatan volume yang ada di RV pulmonary left atrium  enlargement
Juga terdapat systemic insufficiency kalo VSD besar  stimulate Left ventricular enlargement. Jadi tidak ada keterlibatan right atrium
24. e. gambaran PDA adalah leftright shunt dengan adanya left side chambers enlargement dengan adanya prominent pulmonary vascular marking.
25. a. CTR: infant >= 50%; dewasa < 50%
26.
27.
28. bingung. S.Aureus dan S.viridans merupakan leading cause dari endocarditis pada pada pediatric pasien. S.aureus lebih sering pada kejadian tanpa adanya underlying disease, sedangkan s.viridans terjadi lebih sering setelah melakukan dental procedure.. jadi jawabannya antara a/b, tergantung nanti soal mintanya apa..
29.C. untuk prophylaxis antibiotic digunakan penicillin, tapi kalo alergi diaganti cephalixin or clindamycin or azithromycin
30. e. bisa karena infectious microorganism, autoimmune mediated cytotoxicit, cytokine damage. Tapi yang paling sering adalah virus (enterovirus ssRNA that include coxsackie virus dan echovirus)
31. b. komplikasi dari myocarditis adalah : - fatal heart failure dan arrythmia
- myocardial dysfunction
32. C
33.?
34. D. etio dari subacute endocarditis yang saya dapat adalah bakteri gram negative HACEK dan S.viridans.. tapi S.viridans memiliki angka kejadian 50-60% dari subacute endocarditis
39. B. polyarthritis : >=75%; carditis = 40-60%; chorea = 5-36%; erythema marginatum lalu subcutaneous nodule prevelansi hanya angka satuan persen.
40. C. based on major dan minor criteria, paling sering untuk muncul dan memperkuat diagnosis RF adalah major. Maka itu salicylate untuk relieve dari arthritis. Fever dapar diminish tanpa antipyretic therapy dalam 1 minggu atau low grade fever persisten selama 2 minggu.
61. D
62. C
63. A
64. D
65. B (ga yakin,sori)
66. A
67. C
68. ga ada soalnya
69. C
70. D
71. D
72. ga tau,sori
73. C
74. D
75. A
76. A
77. ga tau,sori
78. D
79. D
80. D

161. Of the following statement regarding the ECG of a patient with history of coronary artery disease below is true, except
A. sinus rhythm with 1st degree AV block
B. myocardial infarction, age undetermined
C. pair of PVCs
D. ventricular tachycardia
Jawab: A
Pembahasan:
Dari gambar EKG, terlihat jelas bahwa pasien mengalami tachyarrhythmia (jarak kompleks R ke R berikutnya sempit).
Karena QRS kompleks-nya lebar, maka bisa kita simpulkan bahwa ini adalah ventricular tachyarrhythmia.
Lihat di bagian tengah hingga akhir gambaran EKG, bentuk gelombangnya monomorphic. Maka bisa disimpulkan ini adalah monomorphic ventricular tachycardia. Monomorphic VT biasa terjadi karena adanya abnormalitas struktural yang mendukung terbentuknya suatu reentry circuit, biasanya karena ada myocardial scar karena old infarct atau cardiomyopathy. Secara definisi, VT adalah “a series of three or more VPB/PVCs”.
Jadi option B, C, D benar.
Option A salah karena 1st degree AV block termanifestasi sebagai bradyarrhythmia dengan pemanjangan PR interval.

162. From the features of ECG of a patient in his 5th day in the CCU below, which statement is not?
A. normal sinus rhythm
B. recent myocardial infarction
C. a possible left ventricular aneurysm
D. PACs with trigeminy pattern
E. non-compensatory pause
Jawab: B
Pembahasan:
Dari gambar, terlihat:
1. Ada PAB/PAC (gelombang EKG yang kedua ke yang pertama jaraknya lebih sempit daripada jarak gelombang EKG yang kedua ke yang ketiga).
2. Ada elevasi ST segmen
Maka,
Opsi A salah, ada PAC  bukan sinus rhythm.
Opsi B benar, ada elevasi segmen ST  new/recent myocardial infarction
Opsi C salah, LV aneurysm biasanya ditunjukkan dengan gambaran sustained VT.
Opsi D tidak bisa dinilai, karena trigeminy berarti ada satu PAC dalam setiap 3 beat. Gambar tidak cukup panjang untuk menilai ini.
Opsi E salah, tidak terlihat pause.

163. All the statement below regarding the features of ECG of a 52-year-old male patient with chest pain and hypoventilation are true, except
A. sinus rhythm with 3rd degree AV block
B. 2nd degree AV block type 1
C. functional escape rhythm
D. acute inferior wall myocardial infarction
E. reciprocal ST-T changes at 1, aVL, V1-V4
Jawab: ?? Tidak ada gambaran EKG-nya!
Pembahasan opsi:
Opsi A: sinus rhythm with 3rd degree AV block  secara definisi salah. 3rd degree AV block terjadi jika ada “complete failure of conduction between the atria and ventricles”, berarti depolarisasi atrium (gelombang P) dan depolarisasi ventrikel (kompleks QRS) akan berjalan sendiri-sendiri. Sementara, salah satu syarat sinus rhythm adalah gelombang P yang selalu diikuti kompleks QRS.
Opsi B: 2nd degree AV block type 1  ciri-cirinya ada prolongation dari interval PR dari beat ke beat hingga pada satu titik, impulse dari atrium tidak dikonduksikan ke ventrikel (gelombang P tanpa kompleks QRS), lalu siklus berulang.
Opsi C: functional escape rhythm  ada gambaran PAC (PAB) atau PVB (PVC).
Opsi D: acute inferior wall MI  mungkin saja benar, karena pasien sedang mengalami chest pain.
Opsi E: reciprocal ST-T changes pada lead I, aVL (lateral) dan V1-V4 (anterior)  berarti MI-nya terjadi pada dinding inferior? Sama dengan opsi D.

164. Which of the following statement regarding ventricular arrhythmia in the ECG below is true
A. VCs multifocal, with R-on-T phenomenon, atrial fibrillation
B. VCs multifocal, with R-on-T phenomenon, paired PVC, atrial fibrillation
C. VCs multifocal, with R-on-T phenomenon, paired PVC
D. VCs multifocal, with R-on-T phenomenon, non-sustained ventricular tachycardia
E. VCs multifocal, with R-on-T phenomenon, paired PVC, non-sustained ventricular tachycardia
Jawab: jawaban 2006: C

165. Which of the following statement regarding the features in the ECG below is true?
A. atrial flutter with ventricular facing bea
B. atrial flutter with consecutive PVCs
C. atrial fibrillation
Jawab: C (sepertinya, karena P wave-nya tidak jelas)

166. Which of the following statement regarding atrioventricular block is not true?
A. 2nd degree AV block type I is usually located at the AV nodal level
B. 2nd degree AV block type II is usually located at the intranodal level
C. asymptomatic patients with a 3rd degree AV block at the AV nodal level should have permanent pacing
D. the slight variation in the patients in sinus rhythm and 3rd degree AV block
E. pacing is not indicated in patients with 1st degree AV block
Jawab: C
Pembahasan:
Atrioventricular Block
1. First Degree AV Block
• The impairment of conduction is usually within the AV node itself.
• During first-degree AV block, every atrial impulse conducts to the ventricles and a regular ventricular rate is produced, but the PR interval exceeds 0.20 second in adults.
• Clinically important PR interval prolongation can result from a conduction delay in the AV node (A-H interval), in the His-Purkinje system (H-V interval), or at both sites.
2. Second Degree AV Block
• Mobitz Type I block is usually as a result of intermittent impairment in AV node itself, while Type II block is usually due to that in His-Purkinje system.
• Blocking of some atrial impulses conducted to the ventricle at a time when physiological interference is not involved constitutes second-degree AV block.
• The nonconducted P wave can be intermittent or frequent, at regular or irregular intervals, and can be preceded by fixed or lengthening PR intervals.
• Electrocardiographically, typical type I second-degree AV block is characterized by progressive PR prolongation culminating in a nonconducted P wave , whereas in type II second-degree AV block, the PR interval remains constant prior to the blocked P wave
3. 3rd Degree AV Block
• Third degree or complete AV block occurs when no atrial activity is conducted to the ventricles and therefore the atria and ventricles are controlled by independent pacemakers  complete AV dissociation.
• The atrial pacemaker can be sinus or ectopic (tachycardia, flutter, or fibrillation) or can result from an AV junctional focus occurring above the block with retrograde atrial conduction. The ventricular focus is usually located just below the region of the block, which can be above or below the His bundle bifurcation.
• Complete AV block can result from block at the level of the AV node (usually congenital), within the bundle of His, or distal to it in the Purkinje system (usually acquired).

Management AV block:
• Drugs cannot be relied on to increase the heart rate for more than several hours to several days in patients with symptomatic heart block without producing significant side effects
• temporary or permanent pacemaker insertion is indicated for patients with symptomatic bradyarrhythmias
• For short-term therapy, when the block is likely to be evanescent but still requires treatment or until adequate pacing therapy can be established, vagolytic agents such as atropine are useful for patients who have AV nodal disturbances, whereas catecholamines such as isoproterenol can be used transiently to treat patients who have heart block at any site.
• For symptomatic AV block or high-grade AV block (e.g., infrahisian, type II AV block, third-degree heart block not caused by congenital AV block), permanent pacemaker placement is the treatment of choice

Dari pembahasan di atas, maka
Opsi A benar.
Opsi B benar.
Opsi C salah (3rd degree AV block pada AV nodal level biasanya congenital, jadi tidak perlu pacemaker, apalagi jika asymptomatic).
Opsi D ??
Opsi E benar.

167. Which of the following statements regarding electrical abnormalities in the heart and sudden cardiac death is true?
A. arrhythmic events in patients with long QT syndromes I are often triggered by auditory stimuli
B. the risk of sudden death in Wolff-Parkinson-White Syndrome is high and often occurs in otherwise healthy individuals
C. patients with idiopathic polymorphic ventricular tachycardia have a good prognosis
D. younger patients who survived SCD have a higher incidence of idiopathic ventricular fibrillation
E. most cases of idiopathic ventricular tachycardia originate from the left ventricular outflow tract
Jawab: paling mungkin sih B
Pembahasan:
Opsi A: Long QT syndrome I  Di Braunwald disebutkan, pada LQTS, “Patients should undergo prolonged electrocardiographic recording with various stresses designed to evoke ventricular arrhythmias, such as auditory stimuli, psychological stress, cold pressor stimulation, and exercise.”  arrhythmic events bisa ditrigger oleh auditory stimuli.
Opsi B: Wolf-Parkinson-White Syndrome  the anomalous pathways of conduction, bundles of Kent in the Wolff-Parkinson-White syndrome and Mahaim fibers, are commonly associated with nonlethal arrhythmias. However, when the anomalous pathways of conduction have short refractory periods, the occurrence of atrial fibrillation may allow the initiation of VF during very rapid conduction across the bypass tract .
Opsi C dan E: idiopathic polymorphic VT  polymorphic VT (seperti torsades de pointes) biasanya akan berdegenerasi menjadi VF yang sering menjadi penyebab sudden cardiac death. Jadi, prognosisnya buruk. Opsi E juga kemungkinan salah karena VT tidak mungkin berasal dari outflow tract LV (dekat aorta).
Opsi D: sudden cardiac death.. g nemu.

168. As anti-arrhythmic agent, the mechanism of action of amiodarone is
A. blocking Na channel
B. blocking Ca channel
C. blocking K channel
D. sympatholytic action
E. inhibiting Na-K ATP-ase
Jawab: A
Pembahasan:
AMIODARONE
Effects:
• Acute effects include prolong action potential duration of ventricular muscle but shorten the action potential duration of Purkinje fibers. They also reduce sinus and junctional discharge rates and prolong AV nodal conduction time.
• Chronically, amiodarone prolongs action potential duration and refractoriness of all cardiac fibers without affecting resting membrane potential.
• Hemodynamically, amiodarone is a peripheral and coronary vasodilator. It decreases heart rate, systemic vascular resistance, LV contractile force. However, because it is able to control the arrhythmia, it does not reduce ejection fraction nor cardiac output.
Mechanism of action:
1. It blocks the inactivated sodium channel, therefore reducing maximum conduction velocity.
2. It increases resistance to passive current flow.
3. It antagonizes alpha and beta receptor noncompetitively
4. It blocks conversion of thyroxine (T4) to triiodothyronine (T3)
Sumber: Braunwald

169. Which of the following is the best therapy to relieve symptom in acute pericarditis?
A. oral antisteroidal anti-inflammatory agents and colchicines
B. oral antisteroidal anti-inflammatory agents and indomethacine
C. oral antistreoidal anti-inflammatory agents and corticosteroid
D. corticosteroid: colchicines and indomethacine
E. corticosteroid
Jawab: A
Pembahasan:
Management Acute Pericarditis
Management dari pericarditis bertujuan:
- Deteksi etiologi yang memiliki implikasi terhadap management (misal, jadi harus ganti antibiotic)
- Deteksi effusion dan other echocardiographic abnormalities
- Meringankan symptom
- Treatment yang sesuai dengan etiologi yang spesifik
Acute idiopathic pericarditis merupakan self-limited disease tanpa komplikasi yang significan dan tanpa reccurence pada 70-90% pasien. Jika lab menunjukkan idiopathic acute pericarditis, maka NSAID (biasanya ibuprofen 600-800 mg p.o. tdd) hingga 2 minggu jika nyeri dada sudah tidak dirasakan lagi.
Jika pasien tidak merespon dengan baik pada awal pemberian NSAID, maka sebaiknya diopname untuk observasi dan tes tambahan.
Jika pasien merespon secara lambat, maka diperlukan tambahan analgesic narcotic dan/atau colchicines atau prednisone.
Pada pasien yang mengalami RECURRENT acute idiopathic pericarditis (15-30% dari pasien yang merespon secara memuaskan thd management yang disebutkan di atas), perlu dilakukan evaluasi untuk kemungkinan penyakit autoimmune, dan kadang (jarang) diperlukan biopsi pericardium. Pada kelompok pasien ini, diberikan lagi NSAID selama 2 minggu, lalu diberikan colchicines prophylaxis. Jika pasien tidak membaik, maka diberikan short course of prednisone ketika terasa gejala, namun ini tidak dilakukan secara kronis. Pericardiotomy bisa juga dilakukan, tapi hanya efektif pada sebagian kecil pasien.
Sumber: Braunwald

170. A 30-year-old man came to ER with fever and chest pain. On physical examination, pericardial friction rub was heard. Laboratory finding revealed elevated WBC and ESR. Which of the following is a typical presentation of acute pericarditis?
A. the onset of pain is usually crescendo
B. the patient feels more comfortable in recumbence
C. abnormal S3 and S4
D. pulmonary congestion may be present in severe pericarditis
E. rub can last hours to days
Jawab: A
Pembahasan:
ACUTE PERICARDITIS
Sign and symptom:
6. Chest pain (pasien hampir selalu datang dengan keluhan ini), nyerinya severe. Kualitasnya rapid onset, terletak substernal (bisa juga pada dada kiri atau epigastrium kiri), dan biasa beradiasi ke lengan kiri atau ke trapezius ridge. Nyeri akan membaik jika duduk membungkuk dan akan memburuk jika berbaring.
7. Dyspnea
8. Fever
9. Cough
10. Hiccoughs (hiccups)
Pemeriksaan Fisik:
4. Pasien terlihat uncomfortable, anxious
5. Vital signs: low-grade fever, sinus tachycardia
6. Auskultasi jantung: ada friction rub yang terdiri atas 3 komponen. Komponen pertama terjadi pada ventricular systole, lalu pada early diastolic filling, dan pada atrial contraction. Bunyinya mirip suara berjalan pada crunchy snow. Rub paling terdengar pada lower left sternal border hingga cardiac apex, dan paling keras jika posisi pasien duduk membungkuk. Rub-nya dinamis, kadang muncul kadang menghilang.
Sumber: Braunwald
Dari Lilly disebutkan, onset dari chest pain biasanya crescendo.
Opsi A benar
Opsi B salah, pasien memburuk jika berbaring
Opsi C salah, tidak ada S3 dan S4
Opsi D salah, tidak ada pulmonary congestion
Opsi E salah, karena rub intermittent.

171. Which of the following ECG changes are typical for acute pericarditis?
A. inverted T waves while ST segment still elevated
B. localized convex ST segment elevation
C. diffuse concave ST segment elevation
D. frequent PVCs
E. first degree AV block
Jawab: C
Pembahasan:
Electrocardiogram pada acute pericarditis menunjukkan temuan-temuan sbb:
4. Diffuse ST segment elevation (merupakan classic finding dalam perikarditis akut).
5. Depresi segmen PR  merupakan manifestasi yang lebih awal, biasanya terjadi sebelum ada rub maupun elevasi segmen ST
6. Sangat jarang terjadi elevasi ST yang berprogresi ke depresi segmen ST disertai inversi gelombang T.
Sumber: Braunwald

172. Which of the following statement is true?
A. Acute pericarditis produces dull retrosternal pain
B. Pericardial friction rub is the hallmark of acute pericarditis
C. The stethoscope bell should be placed firmly on the chest wall
D. Most pericardial friction rubs are louder during expiration
E. ASA 650 mg, q3-4th is the drug of choice in recurrent pericarditis
Jawab: B
Pembahasan:
Lihat pembahasan no. 169-170
Opsi A salah, pada acute pericarditis, nyeri dada berkualitas sharp
Opsi C salah, tidak disebutkan bahwa pericardial rub hanya terdengar jika menggunakan bell.
Opsi D salah, pericardial friction rub bisa ada dan menghilang secara tiba-tiba (intermittent).
Opsi E tidak sepenuhnya benar, pada recurrent pericarditis, harus diberikan prophylaxis berupa colchicines juga.
Opsi B benar, karena friction rub paling parah terdengar saat fase pericarditis. Saat fase effusion, friction rub makin melemah. Karena itu, friction rub adalah hallmark dari pericarditis.

173. Which of the following regarding the physical examination of cardiac tamponade is true?
A. Elevation of pericardial pressure, pulsus paradoxus, and arterial hypertension
B. Basal rales are typically present
C. There is rapid x descent, pulsus paradoxus, and arterial hypotension
D. There are rapid x and y descent in the jugular venous pulse
E. There are normal jugular venous pressure and pulsus alternans
Jawab: C
Pembahasan:
Patofisiologi Cardiac Tamponade (CT)
CT dicirikan dengan suatu continuum yang dimulai dari efusi pericardium tanpa efek yang jelas yang berlanjut ke circulatory collapse. Ini tergantung pada tekanan di pericardium (yg meningkat karena efusi) dan kemampuan jantung untuk mengkompensasi peningkatan tekanan tersebut.
Volume cairan di pericardium biasanya hanya sedikit, jadi peningkatan jumlah cairan yang rapid, walaupun dalam jumlah kecil, dapat dengan cepat meningkatkan tekanan pericardium dan berpengaruh pada fungsi jantung. Sebaliknya, slowly accumulating effusion, walaupun jumlahnya besar, dapat ditolerir dengan baik.
Kompensasi jantung bergantung terutama pada respon sympathetic untuk meningkatkan heart rate dan kontraktilitas. Pada pasien yang meminum beta-blocker, maka respon ini minimal dan kompensasi jantung tidak maksimal.
Seiring dengan menumpuknya cairan pada pericardial cavity, akan terjadi peningkatan tekanan diastolic pada ruang-ruang jantung sehingga tekanannya sama dengan tekanan pad pericardial cavity (fenomena ini disebut equalization). Karena meningkatnya tekanan, maka volume darah di jantung akan berkurang (preload berkurang), menyebabkan berkurangnya stroke volume. Karena jantung kanan dindingnya lebih tipis dan kurang bisa beradaptasi terhadap peningkatan tekanan, maka peningkatan tekanan di jantung kanan lebih cepat daripada di jantung kiri (namun pada akhirnya akan mencapai tekanan yg sama, yakni tekanan pericardial cavity).
Kelainan hemodinamik lainnya:
3. Loss of y descent of RA (or systemic venous) pressure (without loss of x descent)
Ini didasarkan pada konsep bahwa, pada severe CT, total heart volume tetap (tidak berkurang maupun bertambah, tidak dipengaruhi oleh kontraksi-relaksasi). Karena itu, darah hanya bisa mengalir ke jantung saat darah (yang tadinya ada di jantung) dipompa keluar. Karena itu, y descent, yang menggambarkan penurunan tekanan atrium setelah atrium berkontraksi, tidak tergambarkan.
4. Paradoxical pulse
Paradoxical pulse menggambarkan berkurangnya tekanan arteri sistemik secara abnormal (>10 mmHg) saat inspirasi. Pada CT (dan secara fisiologis), terjadi peningkatan systemic venous return saat inspirasi (sehingga systemic venous pressure berkurang). Ketika total volume jantung tetap, maka peningkatan venous return ini akan menyebabkan interventricular septum untuk shift to the left saat inspirasi, sehingga membuat LV menjadi sempit, dan stroke volume (LV pressure) berkurang secara abnormal. Karena itu, tekanan arteri sistemik pun berkurang saat inspirasi.
Diagnosis Cardiac Tamponade
f. Anamnesis: pasien mengeluhkan dyspnea, kadang ada pericardial pain atau discomfort, yang akan membaik jika duduk membungkuk (sitting and leaning forward). Terdapat pula gejala-gejala yang berkaitan dengan berkurangnya cardiac output, seperti fatigue, weakness, dizziness.
g. Physical examination: Beck’s triad (hypotension, muffled heart sounds, elevated jugular venous pressure), tachypnea, diaphoresis, cool extremities, peripheral cyanosis, depressed sensorium, yawning. Terdapat pulsus paradoxus. Cardiac impulse tidak ada atau berkurang. Terdapat friction rub.
h. Radiography: = pericardial effusion
i. Electrocardiography: = pericardial effusion
j. Echocardiography: lucent separation between parietal and visceral pericardium is circumferential (usually). Ada collapse dari RV pada saat early diastole dan collapse pada RA pada saat ventricular diastole (kalau tidak ada collapse, biasanya menunjukkan effusion, bukan tamponade).

174. Which of the following statement is NOT true about pathophysiology of cardiac tamponade?
A. Cardiac tamponade occurs when intracardial pressure is equal to RA and RV diastolic pressure
B. In the presence of hypovolemia, cardiac tamponade may be more difficult to detect
C. Equalization of intrapericardial and ventricular filling pressure may lead initially to a small increase in stroke volume
D. Sinus bradycardia may occur during severe cardiac tamponade
E. Hemodynamic deterioration during tamponade is dependent upon atria; compression during diastole
Jawab: C
Pembahasan:
Lihat patofisiologi cardiac tamponade (CT) di no. 173

175. Which of the following statement about bacterial pericarditis is NOT true?
A. Uremic pericarditis may predispose to the development of purulent bacterial pericarditis
B. Direct extension into pericardium of bacterial pneumonia accounts for the majority of cases of purulent pericarditis
C. Bacterial pericarditis is most often an acute fulminant illness that develops over a few days
D. Long term survival after purulent bacterial pericarditis remains poor despite the availability of antibacterial therapy
E. High concentration of antibiotics may be achieved in pericardial fluid
Jawab: A
Pembahasan:
BACTERIAL PERICARDITIS
1. Etiologi
Bacterial pericarditis is usually characterized by a purulent effusion. Direct extension from pneumonia or empyema accounts for a majority of cases. The most common agents are staphylococci, pneumococci, and streptococci. Hematogenous spread during bacteremia and contiguous spread after thoracic surgery or trauma are also important mechanisms. Hospital-acquired, penicillin-resistant staphylococcal pericarditis following thoracic surgery has been increasing. Anaerobic organisms are also increasing in frequency. Concomitant infection in the mediastinum, head, or neck is commonly associated with anaerobes.
2. Clinical Features
The clinical presentation of bacterial pericarditis is usually high-grade fever with shaking chills and tachycardia, but these may be absent in debilitated patients. Patients may complain of dyspnea and chest pain. A pericardial friction rub is present in the majority. Bacterial pericarditis can take a fulminant course with rapid development of tamponade and may be unsuspected because associated illnesses such as severe pneumonia or mediastinitis following thoracic surgery dominate the clinical picture.
3. Management
Suspected or proven bacterial pericarditis should be considered a medical emergency, and prompt closed pericardiocentesis or surgical drainage performed. We recommend at least 3 to 4 days of subsequent catheter drainage. The actual length is dependent on the volume and nature (i.e., purulence) of the fluid. Fluid should be Gram stained and cultured for aerobic and anaerobic bacteria with appropriate antibiotic sensitivity testing. Fungal and tuberculosis staining and cultures should also be performed. Blood, sputum, urine, and recent surgical wounds should all be cultured. Broad-spectrum antibiotics should be started promptly and then modified according to culture results. Anaerobic coverage is critical when pericarditis associated with head and neck infections is suspected.
4. Prognosis
The prognosis of bacterial pericarditis is generally poor, with survival in the range of 30 percent even in modern series

KLASIFIKASI PERICARDITIS (menurut Lilly)
A. Infectious
1. Idiopathic and viral pericarditis
2. Tuberculous pericarditis
3. Nontuberculous bacterial pericarditis (purulent pericarditis)
B. Non-Infectious
1. Pericarditis following myocardial infarction
2. Uremic pericarditis
3. Neoplastic pericarditis
4. Radiation-induced pericarditis
5. Pericarditis associated with connective tissue diseases
6. Drug-induced pericarditis

Opsi A salah, karena uremic pericarditis adalah salah satu jenis pericarditis noninfectious.
Opsi B benar (lihat pembahasan)
Opsi C benar (lihat pembahasan)
Opsi D benar (lihat pembahasan)
Opsi E g nemu, tapi sepertinya benar.

176. Streptococcus sp. Cause endocarditis in about 70% of cases. Streptococcus viridans are the most common pathogens, followed by enterococci. The procedure to detect this organism is obtaining blood for?
A. Bacterial culture
B. Microscopic observed
C. Specific IgG detection
D. Immune detection
E. Hemolytic test
Jawab: A
Pada endocarditis, criteria yang dipakai adalah Duke’s criteria, dimana salah satu major criterianya adalah positive blood culture. Hanya Coxiella burnetti yang boleh didemonstrasikan melalui IgG titer.
Major criteria:
Positive blood culture
Typical microorganism for infective endocarditis from two separate blood cultures
Viridans streptococci, Streptococcus bovis, HACEK group or
Staphylococcus aureus or community-acquired enterococci in the absence of a primary focus, or
Persistently positive blood culture, defined as recovery of a microorganism consistent with infective endocarditis from:
Blood cultures (≥2) drawn more than 12 hr apart, or
All of three or a majority of four or more separate blood cultures, with first and last drawn at least 1 hr apart
Single positive blood culture for Coxiella burnetii or antiphase I IgG antibody titer >1:800

177. Which method is correct to detect a streptococcus in rheumatic fever?
A. Bacterial culture and identification
B. Antistreptolysin O Test
C. Bacteracin test
D. Lancefield test
E. M. protein test
Jawab: B
Pembahasan: cukup jelas :-)

179. Group A streptococcus, which causes rheumatic fever characterized by one of the following mechanism?
A. it produces an erythrogenic toxin
B. it causes beta hemolysis
C. its pathogenicity is by the M protein
D. it causes anti streptolysion O production
E. it produces a hemolysin that dissolves red blood cells
Jawab: C
Pembahasan:
Opsi B, C, D, E benar, tetapi yang berkaitan dengan mekanisme yang menyebabkan rheumatic fever adalah M protein yang secara struktural banyak memiliki kemiripan dengan protein-protein di tubuh.


180. Transient bacteremia is common after minor surgical procedures and bacteria can colonize and multiply in cardiac endothelium. The organism causing endocarditis is all of the following, except …
A. Streptococcus viridans
B. Staphylococcus aureus
C. Staphylococcus epidermidis
D. Escherichia coli
E. Clostridium tetani
Jawab: B
Pembahasan: cukup jelas ya..