cardiology case studies

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Sudden syncope 3 days after MI
Myocardial free wall rupture

Increased O2 sat in PA s/p MI
Increased O2 sat in PA s/p MI
VSD. Red oxygenated blood enters RV and so get increased 02 sat in PA due to red-blue mixing.

Acute MR s/p MI
papillary muscle or chordae tendinae rupture

*pt with bp of 60/palp and EKG shows NSR with normal QRS and alternating Ps with very small QRS and Ps with different axis. What's dx?
*pt with bp of 60/palp and EKG shows NSR with normal QRS and alternating Ps with very small QRS and Ps with different axis. What’s dx?
total electrical alternans due to cardiac tamponade. QRS varies from beat to beat due to pericardium bathing in effusion.
arr

pt with delta waves on ekg? What's the dx and tx
pt with delta waves on ekg? What’s the dx and tx
wpw and no tx usually needed; slurred upstroke and notice short PR esp in II (2 adjacent humps);
arr

*65 y/o with blowing diastolic murmur at RSB. What's dx?
*65 y/o with blowing diastolic murmur at RSB. What’s dx?
chronic AR. notice jetstream from LV diagonally to rt sternal border

Murmur with diastolic rumble and diastolic opening snap
Murmur with diastolic rumble and diastolic opening snap
MS

pt with diastolic murmur along left sternal border
pt with diastolic murmur along left sternal border
TS; see image and remember mnemonic “APTM” for apartment. So Aortic area is RUSB (2nd-3rd Rt IS), Pulmonic area is LUSB(2nd-3rd Lt IS), Tricuspid is LLSB (3rd-6th Lt IS), Mitral is apex (5th-6th IS below mid-clavicular line)

systolic murmur heard best at LLSB
systolic murmur heard best at LLSB
TR; see image and remember mnemonic “APTM” for apartment. So Aortic area is RUSB (2nd-3rd Rt IS), Pulmonic area is LUSB(2nd-3rd Lt IS), Tricuspid is LLSB (3rd-6th Lt IS), Mitral is apex (5th-6th IS below mid-clavicular line)

66 y/o with MAT. Name 3 causes
66 y/o with MAT. Name 3 causes
COPD on theophylline, low K or low Mg; Irreg Irreg, but unlike Afib have P waves which has at least 3 different morphologies.

50 y/o woman with htn, rt sided neck and head pain and dilated rt pupil. What's dx?
50 y/o woman with htn, rt sided neck and head pain and dilated rt pupil. What’s dx?
internal carotid dissection-has good prognosis

Pt with htn tx with hctz develops hypotension. What’s dx?
HCM

blowing early diastolic murmur
chronic AR; “AR she blows”

*pt with short diastolic murmur
acute AR; “short” because AR causes some backflow into LV and so MV will close earlier. May get soft S1, since MV will close in diastole rather than at beginning of systole.

*decrescendo systolic murmur at apex
*decrescendo systolic murmur at apex
acute MR; Apex implies mitral and systolic means MR.

quinidine,procainamide and tricyclics can cause what type of arrhythmia
quinidine,procainamide and tricyclics can cause what type of arrhythmia
torsades de pointes

how does constric pericarditis (cp) differ from restrictive cardiomyopathy (rc)?
how does constric pericarditis (cp) differ from restrictive cardiomyopathy (rc)?
CT shows pericardial thickness of>5mm in cp and rc has elevated BNP unlike cp

venous waveform difference between constric pericard and tamponade?
venous waveform difference between constric pericard and tamponade?
cp-rapid x and y descent
tamponade-rapid x descent only (“tampon in women-no y chromosome”)

35 y/o woman with atypical chest pain and no risks has what chance of sig stenosis in at least 1 coronary artery?
12%

Pt with AS by echo has flow velocity across AV of 4 m/sec. What's the peak systolic gradient across this valve?
Pt with AS by echo has flow velocity across AV of 4 m/sec. What’s the peak systolic gradient across this valve?
Peak pressure=4(v)2 (this is v squared)=4×4(2)= 4×16=64 mm Hg

75 y/o with h/o MI c/o recurrent syncope in past 24 hrs, increasing DOE and EKG showing vtach, av dissociation and apical S3 on exam. What would neck veins show?
Irreg cannon waves due to AV dissoc and large v waves from rt heart failure;

Engorged neck veins without pulsations are due to?
Engorged neck veins without pulsations are due to?
TPtx or SVC obstruction=pulseless neck veins; Neck veins that do pulsate with the heart indicate pericardial tamponade; Image-engorged neck veins and upper chest/neck/head edema from SVC tumor obstruction

*what is the one rt heart sound that does not increase with inspiration?
Pulm ejection sound

1.Pt with pulm htn has what type of heart sound?
2.What causes a single 2nd heart sound?
1.widely split S2
2.severe AS (delayed A2 merges into P2)

What is the significance of a new LBBB at the time of MI?
What is the significance of a new LBBB at the time of MI?
High risk of early mortality due to large amt of myocardium involved. Need urgent revascularization

In STEMI, which fibrinolytic+heparin shows the most favorable effect on mortality.
tPA

85 y/o woman has syncopal episode 4 days after ant MI and becomes unconscious. What’s the dx?
rupture of free wall of LV which leads to large pericardial effusion with collapse of RA and RV. more common in ant MI and usually assoc with syncope.

*75 y/o 3 days post MI with harsh holosystolic murmur heard over precordium and loudest at sternal border
VSD post-MI

22 y/o woman in 3rd trimester of pregnancy with sudden onset of severe interscapular pain and moderate dyspnea along with BP of 165/110. Has soft diast decresc murmur at LLSB. What's Dx?
22 y/o woman in 3rd trimester of pregnancy with sudden onset of severe interscapular pain and moderate dyspnea along with BP of 165/110. Has soft diast decresc murmur at LLSB. What’s Dx?
Acute aortic dissection; increased risk in 3rd trimester and sxs c/w aneurysm in asc aorta and arch making it DeBakeyII or Stanford Type A dissection (A=Asc aorta must be involved+/-desc aorta). Dx with MRI or CT of chest. Will also need 2DE due to AR murmur. Surgery mandatory for asc aorta dissections and can tx htn with nitroprusside and beta-blocker in interim. Type B (asc aorta not involved) can be managed medically initially, but surgery if complications.

85 y/o male with recurrent syncope, carotids with faint transmitted murmur, normal S1 and single S2. +S4. What’s dx
AS; AS is assoc with sudden death. Do not tx with afterload reducers. Even 80 y/os can do well after surgery, but coronary angio is mandatory preop due to risk of CAD in AS.

54 yo man with sudden onset of severe dyspnea,HR of 120, BP of 85/50 with crackles and pulm edema on CXR. Normal CK and troponins. Heart exam shows tachy without obvious extra sounds or murmurs. What’s dx?
Severe MR; requires urgent cardiothoracic consultation due to cardiogenic shock from MR. Murmur not always present in acute MR. Commonest cause in middle-aged men is rupture of myxomatous chordae. Others are endocarditis or isch heart dz.

17 y/o Asian athlete collapses and becomes unresponsive without pulse. EKG shows very large R in I,avL,V5,V6. What’s dx and what arrhythmia is associated?
apical form of HCM seen more in Asians and is assoc with Afib. “AAA”=Apical hcm,Asians, Afib

57 y/o cancer pt with 24 hrs of increasing dyspnea and pleuritic chest pain with BP of 85/40,P-120 and elevated neck veins above clavicle. No murmurs or extra sounds. Breath sounds decr at rt base. Rt heart cath: RA-21,PA-45/20,Wedge-22
Tamponade; Cancers of lung, breast and various lymphomas have mets to pericardium and can cause tamponade. Neck veins are grossly elevated and would get single rapid x descent. Notice diastolic pressures are all nearly equal (21,20,22) which only happens with tamponade and constrictive pericarditis. Beck’s triad is hypotension, elev neck veins and muffled heart sounds (this pt has 1st 2).

Pt with mobitz II 2nd degree HB needs what prior to surgery?
Pt with mobitz II 2nd degree HB needs what prior to surgery?
permanent PM since unlike mobitz I, mobitz II has greater chance of progressing to complete HB.

35 y/o with LDL of 169 with risk factor of obesity tries 3 mos of lifestyle changes, but fails. What next? Statin….?
No. refer for exercise and dietary counseling. Current protocols are strict for pts with CAD or CAD equiv, but for noncompliant pts they can be referred to nutrition, etc.

2 top causes of sudden death in young athlete?
1.HCM-no meds prolong survival. only heart transplant does. B-bl and verapamil may improve sxs.
2.Abnormal (Anomalous) Coronary Arteries

Beta-blocker contraindications in post-MI pt?
2nd or 3rd degree AV block, hypotension, or significant history of bronchospasm

50 y/o male with MI 3 days ago develops severe chest pain and collapses. BP is 70/palp and new loud holosystolic murmur over LLSB. Dx?
VSD due to murmur otherwise free wall rupture also presents with sudden syncope and signs of tamponade; free wall rupture would not have this murmur, but instead signs of tamponade; pap muscle rupture would produce severe MR and pulm edema with short, early systolic-decresc murmur in odd locations.

Which pts are free wall rupture more common in post-MI?
elderly hypertensive women. get secondary tamponade and syncope.

Free wall rupture and VSD are more common in what type of MIs? What about pap muscle dysfunction?
Free wall rupture and VSD-anterior MI (these are big MIs involving big part of heart muscle, producing big complications)
Pap muscle dysfunction-inferior MI (this is smaller MI producing smaller pap muscle problem)

Patient with ASD has what clinical findings?
Pulmonary SEM, widely fixed split S2 and early to mid-diastolic rumble at LLSB due to…..
increased flow from LA to RA which causes increased flow along tricuspid valve which produces early to mid-diastolic rumble at LLSB. This high pressure enters the RV and exits PA causing a pulm ejection systolic murmur and then due to delayed pulmonic valve closure, get widely fixed split S2.

Name 4 components of tetralogy of fallot?
“PROVe”=Pulm Stenosis (aka RV outflow tract obstruction), RVH,Overriding aorta, VSD

Which MI pt benefits most from thrombolytic tx?
Which MI pt benefits most from thrombolytic tx?
Pt with new LBBB has greatest mortality benefit from thrombolytics during ACS due to amt of myocardium in jeopardy. Anterior STEMI benefits next most. Inf STEMI benefit much less. NSTEMI has increased mortality, so NO thrombolytics; Tall R and ST depr in V1&V2 indicates a post MI and this would benefit from thrombolytics, so don’t be fooled by ST depr in this particular case.

What is the safest drug in pregnancy?
Methyldopa. Beta-blockers and labetalol are also commonly used;

Name some common side effects of digoxin?
HAs, blurry vision, N/V,arrhythmias

Rt heart cath findings showing following indicate which 2 possible conditions?
RA pressure-16, PAP-35/15,Wedge-16
Pericardial tamponade and constrictive pericarditis; Both these conditions show equal diastolic pressures in left and rt heart chambers, so RA is 16, PAP diastolic pressure is 15 and Wedge is 16, so these are nearly equivalent. Can use clinical signs to differentiate tamponade from constrictive pericarditis if you have to choose one.

80 yo with exercise induced syncope, CHF signs and 2DE showing thick IV septum and systolic anterior motion of the MV (“SAM”). 3/6 harsh systolic murmur.
What happens to murmur with handgrip and what do you expect with the LVEF?
This is IHSS, a form of hypertrophic cardiomyopathy, so murmur decr with handgrip. EF should be intact (more like diastolic dysfnxn); Carotid upstroke would be brisk and bifid. Murmur would not radiate to carotids. MR is the more likely cause of the murmur.

Do PVCs predict higher mortality in individuals with no known CAD?
No; does increase mortality in pts with known CAD. frequency of PVCs increase with age. common and seen in about 60% of men put on Holters

15 y/o female with PE showing 2+ radial and 1+ femoral pulses. What should you r/o and with what test?
Coarctation, so r/o UE htn by checking BPs in all 4 limbs.

Which conditions do you need dental SBE prophylaxis for?
“PRophylaxis for PR conditions like PRosthetic cardiac valve, PRior h/o endocar, PRior congenital heart dzs-unrepaired cyanotic,completely repaired with PRost material or device for

28 y/o male stabbing chest pain and dysphagia for solids and liquids. What’s the dx and what do you expect on barium swallow?
DES with “corkscrew” pattern on barium swallow; Tx symptomatically with CCBs or antispasmodics. common cause of chest pain in younger people.

74 yo with n,v,lethargy, abd pain, muscle and joint pains. On exam has hyperreflexia and tongue fasciculations EKG shows shortened QT. What’s cause of his sxs?
Hypercalcemia likely due to hyperparathyroidism (bones, moans, groans)-also with tongue fasciculations,etc.

Pt with h/o migraines on prophylaxis presents with confusion, hallucinations, szs, low BP, mydriasis, QRS widening>100ms+/- prolongation of PR and QT intervals +/- high AG metab acidosis. What’s dx?
TCA o/d suggested by wide QRS.

Previously healthy person presents with 1 week of:
Exertional dyspnea and fatigue
Chest discomfort and fullness
Leg edema with clear lungs
Low BP, SBP drops >10 with ispiration
JVD with rapid x descent (nl/ absent y descent)
EKG: sinus tach, low voltage, diffuse ST elevation with some T wave inversions
CXR- enlarged cardiac silhouette
Acute pericarditis with tamponade
Subacute onset, usually idiopathic
Pulsus paradoxus (also in asthma, COPD, PE)
Could see PA cath with equalization of diastolic pressures
DDx – constrictive pericarditis (both x+y descent), MI (different EKG), Ao dissection (no JVD, edema)

*Pt with history of exertional syncope presents with:
Nl PCWP
high RAP
Pulmonary HTN

Pt admitted to the CCU for MI, has CV cath placed in R IJ position, develops:
Recurrent CP
Dyspnea and confusion
Tachypnea, hypotension with decrease in SBP>10 with inspiration
Distended neck veins
Diminished breath sounds on the right
Tension penumothorax
In DDX of post MI decompensation (papillary muscle rupture, free wall rupture, septal rupture), none have pulsus paradoxus, distended neck veins, reduced breath sounds
Can also see in pt on vent with high levels of PEEP

*Young patient with long history of fatigue, exercise intolerance, episodic palps presents with acute onset of:
R hand weakness and dysarthria
Nl JVP but irregular pulse
No edema
Wide, fixed split S2 when standing
Midsystolic ejection murmur at 2nd ICS on L
EKG- tachycardic, sawtootth morphology
CXR- RA enlargement
Atrial septal defect, now with atrial flutter and embolic CVA
ASD->RAE->A. flutt-> CVA
Can also see 1st degr AV block, R axis deviation, incomplete RBBB
If severe RV overload, development of pulm HTN, can see fixed split S2. S2 gets louder with pulm HTN

*Young patient with history of primary Raynaud syndrome presents with:
Acute chest discomfort
HTN
Positive UDS for cocaine
EKG: ST elevation >1mm in II, III, aVF, returns to nl as soon as chest discomfort subsides
Cath- nl coronaries
Variant angina (Prinzmetals)
Characterized by vasospasm which is usually inferior distrib
MI- EKG doesn’t return to nl that quick
See it more often in pts with H/O raynauds

*Pt with hyperlipidemia, HTN now with MI, 3 days ago:
Acute dyspnea
Hypotension
Bilateral rales +/- JVD
Hyperdynamic precordium with new systolic murmur at the apex with wide radiation
Papillary muscle rupture
See acute onset new MR murmur

*Patient post-MI 3 days with:
Hypotension
JVD, bilateral rales, edema
Hyperdynamic precordium with a thrill, new loud, harsh, holosystolic murmur at the LLSB with wide radiation
Ventricular septal rupture
Get biventricular failure, murmur in different location

*Pt with MI, now 3-5 days out, presents with:
Acute recurrent CP
Nausea
Restlessness
Hypotension
PR prolongation and ST elevation consistent with pericarditis
Ventricular free wall rupture
Leads to tamponade, then death
This was an incomplete rupture that clotted over

60 y/o male presents with
Acute, severe, sharp CP, radiating to back and abdomen
Hypotension, >20 SBP between the upper extremities
Nl JVP
Diastolic, decrescendo murmur loudest at R 2nd ICS
EKG: non-specific ST, T wave changes
CXR- widened mediastinuim
Aortic dissection
With dissection near the AoV, can see it affect coronaries, give MI like EKG changes, but the pain here is like dissection
Tearing, ripping, sharp pain

*Pt with bicuspid aortic valve presents with:
Dyspnea on exertion
High SBP, low DBP, water hammer pulse
High pitched, blowing diastolic murmur, loudest ar R 2nd ICS (or L 4th ICS) with leaning forward; increased with squat, decrease with valsalva
+/- diastolic rumble murmur, loudest at apex
Chronic aortic regurgitation
Assc with bifid valve, marfans
Wide pulse pressure
If severe, can see with L HF
Acute (endocarditis) different presentation

Pt. with recent history of ischemic HD and CABG presents with days to weeks H/O:
Fatigue
Recurrent chest discomfort
Fever
Leukocytosis
+/_ pericardial friction rub
CXR- increased cardiac silhouette
Post-pericardiotomy syndrome
Without the H/O CABG, it would have been acute pericarditis- the surgery is the key!
Similar to post-MI infarction syndrome (Dressler’s)

70 y/o male s/p large ant MI presents 3 days later with abd pain, mottled extremities with bluish-black toes. BP-140/75. What’s dx?
*LV Apical aneurysm with secondary emboli to mesentery (abd pain) and to extremities. Unlike other post-MI complics leading to shock (vsd,pap rupture, free wall rupture), this one has normal BP

Which of the following is not an indication for stopping a treadmill test?
a)SBP drop of >15mm Hg
b)ST depr>1.5 mm
c)Chest pain, light-headedness or sob
d)Vtach
a)ST depr>1.5mm. Would be stopped for ST depr>2mm. A positive stress test is ST depr>1mm for >0.08s.

Which of following least supports dx of acute pericarditis?
a)Elevated serum CPK
b)PR depr esp in lead II
c)Frequent APBs
d)Absence of pericardial rub
e)Diffuse TwI and ST elevation
e)-this would indicate MI. Others are supportive of acute pericarditis-incr CPK, PR depr, APBs, diffuse concave up ST elevs without the TwI, etc.

What is the most common congenital heart dz causing cyanosis in infants?
TGV-transposition of the great vessels

Post-MI pt is scheduled for elective hernia repair. When is best time to do surgery?
After 6 mos. Within 3 mos, risk is 37% and after 6 mos drops to 4-5%. No stress test needed if exercising or doing 4-5 METs activity without sxs (mowing lawn, etc.);

What size AAA would you refer to vascular surgery for repair?
>5.5cm. “AAA recommends keeping both hands or 5&5 on the wheel=5.5cm”; If 4-5.5cm, then do Usx every 6-12 mos and if <4cm then every 2-3 yrs.

Pt with severe COPD with angina is put on nitrates and will be put on B-bl. Which ones would you choose?
Atenolol or Metoprolol are selective (“Ace Met Ate”) as is Acebutolol. These are the preferred ones in severe bronchospastic dz

Which drug should never be used for wide complex tachy in emergent setting?
CCBs

EKG with ST elevs in multiple leads with prominent J points T waves exceeding the corresponding ST elevs and notching or the terminal QRS describes what?
Early or normal repolarization variant.

37 y/o IVDA with prominent jugular venous v waves and systolic murmur that gets louder with inspiration would have what on 2DE and on V/Q scan?
This is a case of TR due to endocarditis. 2DE would show large vegetation and V/Q would likely show multiple perfusion defects due to septic pulm emboli

42 y/o pt with syncope and chest pain. R/O for MI. PE shows prominent neck v waves, prominent left parasternal lift, S3 at left sternal border, pulsatile liver and Kussmaul’s sign in neck veins. Rt leg has mild edema. Got cath down with clean coronary arteries and normal ventricular fnxn. What’s dx and what test done to find underlying cause?
P’htn and do V/Q next since it’s likely due to multiple PEs given normal heart work-up and edematous leg which is likely due to thrombus which threw the PEs

39 y/o male with sudden onset of severe chest pain radiating down both arms. PE shows he has high arched palate. What's next test to do?
39 y/o male with sudden onset of severe chest pain radiating down both arms. PE shows he has high arched palate. What’s next test to do?
Get contrast chest CT or TEE to r/o aortic dissection. High arched palate indicates Marfan’s.

Which commonly used OTC analgesic can raise INR by interacting with coumadin?
Acetaminophen. Rx Bactrim also can raise INR.

We use cookies to give you the best experience possible. By continuing we’ll assume you’re on board with our cookie policy DOE, PND, edema. Echo w/ LVH or RVH, hypokinesis CHF S3 CHF, dilated cardiomyopathy WE WILL WRITE A CUSTOM …

We use cookies to give you the best experience possible. By continuing we’ll assume you’re on board with our cookie policy 2 layers of pericardium Parietal = fibrous external Visceral = adjacent to epicardium Normal fluid level of serous fluid …

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We use cookies to give you the best experience possible. By continuing we’ll assume you’re on board with our cookie policy Fibrillation Rapid, random and ineffective heart contraction. Endocardium The inner layer of the heart. WE WILL WRITE A CUSTOM …

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We use cookies to give you the best experience possible. By continuing we’ll assume you’re on board with our cookie policy 59 A 7mo old boy with respiratory difficulty is brought to the ED at 3AM. His mother reports that …

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