Cardiovascular

1. Cardiovascular Step 2 Review Qns

2. OBJECTIVES FOR THIS WEEK • Basic understanding of the electrical and mechanics of the heart • How it fails and clear understanding of the differing manifestations of each type of failure. • Management of basic cardiovascular etiologies • EKG • Murmur and associated findings

3. Case 1 A 68 year-old woman with a history of HTN and DM presents with shortness of breath. She denies any chest pain and palpitations. Physical examination reveals a blood pressure of 130/60 mmHg and a heart rate of 72/min. The patient’s lungs are normal, and heart auscultation reveals an S4 gallop. She has no JVD and no peripheral edema. Chest radiograph shows a normal-size heart, and ECG shows left ventricular hypertrophy. Echocardiogram reveals concentric left ventricular hypertrophy with a hyperdynamic left ventricle. Which of the following is the most likely diagnosis? • Systolic dysfunction • Diastolic dysfunction • Left heart failure • Right heart failure • Normal heart

4. Case 2 A 50 year-old woman presents with malaise and weight loss. She denies chest pain, shortness of breath, dizziness, and palpitations. Her temperature is 100.90F, and her heart rate is 80/min. There is a diastolic murmur that is variable from cycle to cycle. Splinter hemorrhages are visible in the fingernails of both hands. Which of the following is the most likely diagnosis? • Mitral stenosis • Endocarditis; • Aortic insufficiency • Atrialmyxoma • Tricuspid stenosis

5. Case 3 A 57 year-old man presents with mid-sternal pressure-like chest pain that radiates to the left arm accompanied by diaphoresis and nausea. He has a blood pressure of 80/50 mmHg and neck vein distension with inspiration. The rest of the physical examination is normal. Electrocardiogram reveals ST elevations in leads 2, 3 and AVF. Which of the following is the most likely diagnosis? • Congestive heart failure • Pericardial tamponade • Right ventricular infarction • Rupture of chordinaetendinae • Rupture of the papillary muscle

6. Case 4 A 47 year –old man has been at home recovering from an anterior myocardial infarction that occurred 10 days ago. He presents to your office complaining of persistent chest pain that is worsen on inspiration and that is different from his heart attack pain. The pain radiates to both clavicles. The pain is worse when the patient is lying down and improves with sitting up and leaning forward. The patient has temperature of 101.20F and a normal blood pressure. Heart auscultation reveals a pericardial rub. Lung examination is positive for dullness and diminished breath sounds and at the right base. Chest radiograph reveals a small right-sided pleural effusion. Laboratory data reveals that the patients has a mild leukocytosis and with an increased sedimentation rate (ESR). Which of the following is the most likely diagnosis? • Extension of the myocardial infarction • Unstable angina • Prinzmental’s angina • Pulmonary embolus • Post-myocardial infarction syndrome

7. Case 5 A 26-year-old woman presents to the ER complaining of a sudden onset of palpitations and severe shortness of breath and coughing. She reports that she has had several episodes of palpitations in the past, often lasting a day or two, but never with dyspnea like this. She has a history of rheumatic fever at age 14 years. She is now 20 weeks pregnant with her first child and takes prenatal vitamins. She denies use of any other medications, tobacco, alcohol, or illicit drugs. On examination, her heart rate is between 110 and 130 bpm and is irregularly irregular, with a BP of 92/65 mmHg, and a respiratory rate of 14 breaths per minute with an oxygen saturation of 92% on room air. She appears uncomfortable with labored respirations. She is coughing, producing scant amount of frothy sputum with a pinkish tint. She has ruddy cheeks and a normal jugular venous pressure. She has bilateral inspiratory crackles in the lower lung fields. On cardiac examination, her heart rate is irregularly irregularly with a loud S1 and a low-pitched diastolic murmur at the apex. Her apical impulse is non-displaced. Her uterine fundus is palpable at the umbilicus, and she has no peripheral edema. An EKG is obtained (see figure below).

8. A. What are your differential diagnosis?B. What is your most likely diagnosis?C. What is your next step in management?

9. Case 6 You are working in the cardiac intensive care unit and are called to deal with a cardiac arrest. The patient is a 36-year-old female who was admitted with dehydration in the setting of a gastrointestinal illness. She has had profound vomiting and diarrhea for the last 4 days with 10 recorded stools. In addition, the patient is known to be an alcoholic who drinks a pint of vodka daily. On arrival, the patient is in full cardiac arrest without pulse, and the nursing staff has initiated basic cardiopulmonary life support. The patient has been intubated. The patient’s rhythm is shown below. Which of the following drugs would be most helpful in correcting this rhythm?

10. Magnesium sulfate Amiodarone Sodium bicarbonate Calcium chloride Lidocaine

11. Case 7 A 40-year-old male with diabetes and schizophrenia is started on antibiotic therapy for chronic osteomyelitis in the hospital. His osteomyelitis has developed just underlying an ulcer where he has been injecting heroin. He is found unresponsive by the nursing staff suddenly. His electrocardiogram is shown below (Lead aVL, Lead V1, Lead1, respectively). The most likely cause of this rhythm is which of the following substances?

12. Furosemide Metronidazole Droperidol Metformin Heroin

13. Case 8 A 73-year-old male with a long history of diabetes, cigarette smoking, and hypertension is admitted to the hospital with shortness of breath, near syncope, and hypotension. A Swan-Ganz catheter is placed and reveals a cardiac index of 1.3 L/min per m2, pulmonary artery (PA) pressure of 44/22 mmHg, renal artery (RA) pressure of 18 mmHg, and pulmonary capillary wedge (PCW) pressure of 5 mmHg. The patient most likely has

14. Case 8- MCQ • Aortic stenosis • Cor pulmonale • Mitral stenosis • Occlusion of the left anterior descending coronary artery • Pericardial tamponade

15. Tell the EKG pattern

16. Atrial fibrillation • Irregularly irregular rhythm with no discernible P waves. • Rate btw 100 and 180 bpm • Ventricular response may be < 100 bpm if the patient is taking Digoxin, verapamil, or beta- blocker or has AV nodal disease • See in some healthy individuals BUT commonly assoc with organic heart dz (CAD, hypertensive heart dz, or Rheumatic mitral valve dz), thyrotoxicosis, alcohol abuse, pericarditis, PE, and postop REMEMBER: “I SMART CHAP” Rx: • Slow down ventricular response- IV adenosine, verapamil, diltiazem, digoxin, & beta-blockers • Maintain or convert to sinus rhythm- quinidine, amiodarone, procainamide • In patients with increased M.ischemia, hypotension, or pulm edema, use DC-synchronized Cardioversion

17. Tell the EKG pattern

18. Paroxysmal atrial tachycardia (PAT) A run of 3 or more consecutive PACs (ectopic atrial focus firing prematurely followed by a normal QRS). HR between 140 and 250 bpm P-wave may not be visible, but the RR interval is very regular Can be seen in healthy individuals but also occurs with a variety of heart dz. Symptoms include: palpitations, light-headedness, and syncope Rx: • Increase vagal tone- valsalva maneuver or carotid massage • Medical treatment- adenosine, verapamil, digoxin. Be careful with verapamil & beta-blockers as they cause ASYSTOLE. • Cardioversion with synchronized DC shock

19. Tell the EKG pattern

20. Ventricular Tachycardia By definition, 3 or more PVCs in a row. A wide QRS usually with an LBBB pattern. Can be life-threatening because of hypotension and tendency to degenerate into ventricular fibrillation. Treatment of nonsustained VT is controversial. Patients with ventricular aneurysm are more susceptible to develop ventricular arrhythmia, especially in the presence of cardiac dz.

21. EKG pattern pls?

22. Premature atrial contraction (PAC) Ectopic atrial focus firing Can be caused by stres, caffeine, and myocardial dz

23. EKG patter pls?

24. How do you feel so far? • More CVS cases next week! • New system review will also commence next week • Thank you !