Transcript Step 2 Review Qns OBJECTIVES FOR THIS WEEK

Cardiovascular
Step 2 Review Qns
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
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?
a.
b.
c.
d.
e.
Systolic dysfunction
Diastolic dysfunction
Left heart failure
Right heart failure
Normal heart
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?
a.
b.
c.
d.
e.
Mitral stenosis
Endocarditis;
Aortic insufficiency
Atrial myxoma
Tricuspid stenosis
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?
a.
Congestive heart failure
b. Pericardial tamponade
c.
Right ventricular infarction
d. Rupture of chordinae tendinae
e.
Rupture of the papillary muscle
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?
a.
b.
c.
d.
e.
Extension of the myocardial infarction
Unstable angina
Prinzmental’s angina
Pulmonary embolus
Post-myocardial infarction syndrome
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).
A. What are your differential diagnosis?
B. What is your most likely diagnosis?
C. What is your next step in management?
Case 6
You are working in the cardiac intensive care unit and are
called to deal with a cardiac arrest. The patient is a 36year-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?
A.
B.
C.
D.
E.
Magnesium sulfate
Amiodarone
Sodium bicarbonate
Calcium chloride
Lidocaine
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?
A.
B.
C.
D.
E.
Furosemide
Metronidazole
Droperidol
Metformin
Heroin
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
Case 8- MCQ
A.
B.
C.
D.
Aortic stenosis
Cor pulmonale
Mitral stenosis
Occlusion of the left anterior descending coronary
artery
E. Pericardial tamponade
Tell the EKG pattern
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
Tell the EKG pattern
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
Tell the EKG pattern
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.
EKG pattern pls?
Premature atrial contraction (PAC)
Ectopic atrial focus firing
Can be caused by stres, caffeine, and myocardial dz
EKG patter pls?
• How do you feel so far?
• More CVS cases next week!
• New system review will also commence
next week
• Thank you !