20190117-20190123 Flashcards
A 25-year old woman comes to the physician for a routine exam. She is healthy and experiences no symptoms however on cardiac examination a mid-systolic click is heard. Which of the following valvular abnormalities is most likely present in this patient?
a. Ballooning of valve leaflets
b. Fibrous bridging between thickened, leaflets
c. Irregular beads of calcification in annulus
d. Large, bulky vegetation with adjacent leaflet perforation
e. Tiny vegetations along the line of closure of valve leaflet
A 25-year old woman comes to the physician for a routine exam. She is healthy and experiences no symptoms however on cardiac examination a mid-systolic click is heard. Which of the following valvular abnormalities is most likely present in this patient?
a. Ballooning of valve leaflets
b. Fibrous bridging between thickened, leaflets
c. Irregular beads of calcification in annulus
d. Large, bulky vegetation with adjacent leaflet perforation
e. Tiny vegetations along the line of closure of valve leaflet
Explanations:
A – mitral valve prolapse, B – Mitral stenosis (rheumatic fever), C – Elderly individuals (normal aging), D – Acute bacterial endocarditis, E – Marantic (nonbacterial thrombotic) endocarditis
Learning objectives:
146a Explain the abnormal hemodynamics created by regurgitation of the aortic and mitral valves, which translate into the physical findings and abnormalities in chest X-ray and echocardiography.
152a Describe the common afflictions of the cardiac valves. For each disease process, know which valves are affected, and the pathophysiological outcome of the disease process (i.e. stenosis, insufficiency, etc.)
152a Describe how the pathological changes during the normal aging process lead to valvular dysfunction
152a Justify the assertion that valvular pathology and dysfunction can arise not only from changes to the valve leaflets themselves, but also from pathology affecting the supporting structures including the annulus, chordae tendineae, papillary muscles, and ventricular free wall
A 13-yr-old boy is brought to the physician because of pain and swelling in his knees and ankles along with a recent onset fever. He had an upper respiratory infection two weeks ago, for which he received acetaminophen. His temperature is 100.4F, pulse is 110/min, respirations are 22/min, and blood pressure is 115/76 mmHg. Physical exam shows erythematous skin macules with a clear center, arthritis, and small subcutaneous nodules on the dorsal aspect of the arms. A systolic murmur in the mid-precordial area is heard on auscultation of the chest. Which valvular issue best explains this patient’s symptoms.
a. Mitral stenosis
b. Tricuspid regurgitation
c. Mitral regurgitation
d. Tricuspid stenosis
e. Aortic stenosis
A 13-yr-old boy is brought to the physician because of pain and swelling in his knees and ankles along with a recent onset fever. He had an upper respiratory infection two weeks ago, for which he received acetaminophen. His temperature is 100.4F, pulse is 110/min, respirations are 22/min, and blood pressure is 115/76 mmHg. Physical exam shows erythematous skin macules with a clear center, arthritis, and small subcutaneous nodules on the dorsal aspect of the arms. A systolic murmur in the mid-precordial area is heard on auscultation of the chest. Which valvular issue best explains this patient’s symptoms.
a. Mitral stenosis
b. Tricuspid regurgitation
c. Mitral regurgitation
d. Tricuspid stenosis
e. Aortic stenosis
Explanation: Rheumatic fever, S. pyogenes = mitral regurgitation
Learning objecgtives:
152a Describe the common afflictions of the cardiac valves. For each disease process, know which valves are affected, and the pathophysiological outcome of the disease process (i.e. stenosis, insufficiency, etc.)
152a Describe the key pathological features of both acute and chronic rheumatic heart disease
152a Describe the factors predisposing to and the complications of infective endocarditis
A 75 year old woman is noted to have a pulsatile mass in her abdomen on physical exam. She is not experiencing any pain. All laboratory values are within normal limits. Which of the following is the best option for further management?
A. Immediate transfer to surgery, followed by open repair
B. Biopsy
C. Obtain imaging, if <5.5 cm, close observation with repeat imaging
D. Obtain imaging to prepare for endovascular repair
A 75 year old woman is noted to have a pulsatile mass in her abdomen on physical exam. She is not experiencing any pain. All laboratory values are within normal limits. Which of the following is the best option for further management?
A. Immediate transfer to surgery, followed by open repair
B. Biopsy
C. Obtain imaging, if <5.5 cm, close observation with repeat imaging
D. Obtain imaging to prepare for endovascular repair
Explanation: The patient has AAA. Management of AAA is based on symptom and size: if the patient is symptomatic or there are concerns of rupture, surgical repair is the first option. Otherwise, the management is based on size of AAA. If the size is < 5.5cm, can be managed with repeat CT. If the size is > 5.5cm, go for surgical repair.
Learning objectives:
153a Understand the pathophysiology and treatment options for abdominal aortic aneurysms
Which of the following is NOT a risk factor for aortic aneurysm?
A. Marfan syndrome.
B. Hyperlipidimia and atherosclerosis.
C. Smoking
D. Diabetes
Which of the following is NOT a risk factor for aortic aneurysm?
A. Marfan syndrome.
B. Hyperlipidimia and atherosclerosis.
C. Smoking
D. Diabetes
Explanation: Aortic aneurysm is now believed to be caused by inflammatory cells releasing cytokines, leading to production of matrix metalloproteases that weakens the extracellular matrix in the blood vessel (degradation of collagen and elastin). This weakens the blood vessel structure and results in the formation of aneurysm. Marfan syndrome is a genetic disease of fibrillin mutation that results in absnormal connective tissue. Hyperlipidemia and associated atherosclerosis also results in weakening of the media of artery and formation of aneurysm. Other associated risk factors include smoking, old age, and male. African American descent and diabetes are actually protective against aneurysm.
Learning objectives
153a Explain the etiology of aneurysm formation and the pathophysiologic consequences of this disease
A 67 year old African American male presents with pain in his lower legs. This pain happens usually after about 4 blocks and goes away after he rests a bit. PMH is notable for smoking. Vitals: HR 80, RR 12, BP 151/82, Temp 97, Weight 240, Height 5’7. PE, PMH, SH, FH unremarkable. Which of the following is the most appropriate initial intervention for this patient?
A. Low dose aspirin daily
B. Clopidogrel
C. Revascularization
D. Lifestyle modification
E. Prophylatic toe amputation
A 67 year old African American male presents with pain in his lower legs. This pain happens usually after about 4 blocks and goes away after he rests a bit. PMH is notable for smoking. Vitals: HR 80, RR 12, BP 151/82, Temp 97, Weight 240, Height 5’7. PE, PMH, SH, FH unremarkable. Which of the following is the most appropriate initial intervention for this patient?
A. Low dose aspirin daily
B. Clopidogrel
C. Revascularization
D. Lifestyle modification
E. Prophylatic toe amputation
Explanation: The patient has claudication. The symptom is consistent with an early stage of the disease. The best option would be exercise, and lifestyle modification.
Learning objective:
153a Explain the natural history and pathophysiology of peripheral arterial disease
A 4-month-old is noted to have a grade 3/6, harsh, systolic ejection murmur heard at the left upper sternal border. The mother reports that the child’s lips occasionally turn blue during feeding. A cardiologist recommends surgery. Later, the physician remarks that the infant’s congenital abnormality was related to a failure of neural crest cell migration. Prior to surgery, which of the following was a likely finding?
A. Atrial septal defect
B. Transposition of great vessels
C. Tricuspid atresia
D. Coarctation of aorta
E. Pulmonary stenosis
A 4-month-old is noted to have a grade 3/6, harsh, systolic ejection murmur heard at the left upper sternal border. The mother reports that the child’s lips occasionally turn blue during feeding. A cardiologist recommends surgery. Later, the physician remarks that the infant’s congenital abnormality was related to a failure of neural crest cell migration. Prior to surgery, which of the following was a likely finding?
A. Atrial septal defect
B. Transposition of great vessels
C. Tricuspid atresia
D. Coarctation of aorta
E. Pulmonary stenosis
Explanation: The presentation of cyanotic spells with activity (feeding) are most consistent with Tetralogy of Fallot (TOF), a congenital cardiac defect characterized by (1) pulmonic stenosis, (2) ventricular septal defect, (3) overriding aorta, and (4) right ventricular hypertrophy. The murmur is consistent with pulmonary stenosis.
A. Atrial septal defect (ASD), a non-cyanotic heart lesion, is not a component of TOF. ASDs often do not present until reversal of the left to right shunt due to development of secondary pulmonary hypertension (Eisenmenger syndrome).
B. Transposition of the great vessels (aorta and the pulmonary artery) is another cyanotic congenital cardiac abnormality that will present at birth or shortly thereafter. However, it is not associated with abnormal heart sounds.
C. Tricuspid atresia is a cardiac defect in which the tricuspid valve is missing or abnormally developed, blocking blood flow from the right atrium to the right ventricle. A cyanotic lesion, it will present with bluish skin from birth.
D. Coarctation of the aorta is a narrowing of the aorta that results in decreased blood pressure in the legs compared to the arms. It can present with leg pain on exercise.
Learning objective:
151a
Describe the pathology and pathophysiology of major forms of congenital heart diseases.
Explain the pathogenesis of Eisenmenger’s syndrome
A 4-year-old Caucasian male suffers from cyanosis and dyspnea relieved by squatting. What is the mechanism for the symptomatic relief?
A. Increased right heart pressure leading to better flow in the pulmonary circulation and better oxygenation.
B. Increased systemic resistance resulting in higher left ventricular pressure.
C. Increased left side pressure leading to reverse flow in the atrial septal defect.
D. Increased flow from pulmonary circulation to systemic circulation.
A 4-year-old Caucasian male suffers from cyanosis and dyspnea relieved by squatting. What is the mechanism for the symptomatic relief?
A. Increased right heart pressure leading to better flow in the pulmonary circulation and better oxygenation.
B. Increased systemic resistance resulting in higher left ventricular pressure.
C. Increased left side pressure leading to reverse flow in the atrial septal defect.
D. Increased flow from pulmonary circulation to systemic circulation.
Explanation: The patient has what’s called a “tet-spell,” and should prompt thinking about tetralogy of Fallot: 1) infundibular pulmonary stenosis; 2) ventricular septal defect; 3) right ventricular hypertrophy; and 4) overriding aorta. The cyanotic symptom is due to increased right to left shunt as a result of pulmonary stenosis, VSD and overriding aorta. Squatting increase systemic vascular resistance, thereby increasing left ventricular pressure and reduce the right to left shunting.
Learning objective:
150a Define a congenital complex and contrast this with an individual anomal
150a Describe Tetralogy of Fallot and contrast cyanotic Tetralogy of Fallot from acyanotic Tetralogy of Fallot
Baby A was a 3,180 g male infant born by spontaneous vertex delivery at 38 weeks gestational age. The mother, a 29-year-old gravida 2, para 1, had an uneventful antenatal period with normal prenatal ultrasound scans. She had normal serology and no history of sepsis. The labor and delivery were uncomplicated, and Baby A was born in good condition. At his first newborn physical examination at 12 hours of age, Baby A appeared morphologically normal, with a normal cardiac examination. He bottle-fed well over day 1 and was discharged home with his mother on day 2.
Both mother and infant were reviewed daily by the community midwifery team. However, on day 4, the infant was noted by his mother to be increasingly tachypneic, and his feeding had deteriorated. The infant was evaluated by the general practitioner, who referred him to the regional NICU for ongoing care.
On clinical examination in the NICU, the infant was found to be irritable but alert. There was mild cyanosis in room air. He was tachypneic with a respiratory rate of 80 to 90 breaths per minute, a labored respiratory pattern, and mild subcostal retractions. Breath sounds were clear on auscultation.
The heart rate was regular, and on auscultation, there was a grade 3/6 systolic murmur
loudest over the left lower sternal margin, a gallop rhythm, and right ventricular heave. The femoral pulses were difficult to palpate, but brachial pulses were present. The liver edge was palpable 1cm below the right coastal margin.
What is the first step of management?
A. Start prostaglandin E infusion.
B. Obtain CT of the chest.
C. Prepare for emergency open-heart surgery.
D. Prepare for emergency balloon septostomy.
Baby A was a 3,180 g male infant born by spontaneous vertex delivery at 38 weeks gestational age. The mother, a 29-year-old gravida 2, para 1, had an uneventful antenatal period with normal prenatal ultrasound scans. She had normal serology and no history of sepsis. The labor and delivery were uncomplicated, and Baby A was born in good condition. At his first newborn physical examination at 12 hours of age, Baby A appeared morphologically normal, with a normal cardiac examination. He bottle-fed well over day 1 and was discharged home with his mother on day 2.
Both mother and infant were reviewed daily by the community midwifery team. However, on day 4, the infant was noted by his mother to be increasingly tachypneic, and his feeding had deteriorated. The infant was evaluated by the general practitioner, who referred him to the regional NICU for ongoing care.
On clinical examination in the NICU, the infant was found to be irritable but alert. There was mild cyanosis in room air. He was tachypneic with a respiratory rate of 80 to 90 breaths per minute, a labored respiratory pattern, and mild subcostal retractions. Breath sounds were clear on auscultation.
The heart rate was regular, and on auscultation, there was a grade 3/6 systolic murmur
loudest over the left lower sternal margin, a gallop rhythm, and right ventricular heave. The femoral pulses were difficult to palpate, but brachial pulses were present. The liver edge was palpable 1cm below the right coastal margin.
What is the first step of management?
A. Start prostaglandin E infusion.
B. Obtain CT of the chest.
C. Prepare for emergency open-heart surgery.
D. Prepare for emergency balloon septostomy.
Explanation: The baby is likely having coarctation of aorta above the ductus level. The patent ductus during the first few days allow for normal flow, but the gradual closure of the ductus removes a shunt from pulmonary circulation to systemic circulation, and inadequate oxygenation below the coarctation can result in cyanosis. The most important thing at this stage is to maintain the shunt by infusing prostaglandin E. Balloon septostomy is used only in transposition of great arteries in which the existing shunting is not sufficient to maintain the mixing of oxygenated and deoxygenated blood and there is a need to create second communication between the two blood pools.
Learning objective:
150a Define a congenital complex and contrast this with an individual anomaly
150a Describe the natural history of shunts and the typical pathophysiological changes that can ensue from shunts at various levels
150a Define obstruction, and describe the various obstructions that can be found at different anatomic levels on both the right and left sides of the heart
Which of the following anomaly likely results in right heart hypertrophy?
A. Patent ductus arteriosus.
B. Ventricular septal defect at the outflow track.
C. Atrial septal defect.
Which of the following anomaly likely results in right heart hypertrophy?
A. Patent ductus arteriosus.
B. Ventricular septal defect at the outflow track.
C. Atrial septal defect.
Explanation: The only scenario that would result in increase flow of blood into the right ventricle is ASD. Other two pathologies would result in increase flow of blood through the left side of the heart.
Learning objective:
150a Describe the natural history of the various obstructions, and the typical pathophysiological changes that can ensue
Which of the following conditions are not likely to result in Eisenmenger’s Syndrome?
A. Pulmonary stenosis.
B. Coarctation of aorta.
C. Atrial septal defect.
D. Ventricular septal defect.
Which of the following conditions are not likely to result in Eisenmenger’s Syndrome?
A. Pulmonary stenosis.
B. Coarctation of aorta.
C. Atrial septal defect.
D. Ventricular septal defect.
Explanation: Eisenmenger’s Syndrome results from increase right to left shunt and patient often exhibit cyanosis. To have increased right to left shunt, you need two things: 1) structural defect, and 2) increased pulmonary resistance. The increased pulmonary resistance can be due to primary defect of pulmonary outflow (eg. pulmonary stenosis) or increased flow through the pulmonary vasculature (eg. ASD, VSD, and less often PDA). When pulmonary resistance raised above systemic resistance, the pressure difference allows the establishment of right to left shunt.
Learning objecitve:
150a Describe the natural history of shunts and the typical pathophysiological changes that can ensue from shunts at various levels
150a Describe the natural history of the various obstructions, and the typical pathophysiological changes that can ensue
150a Explain the steps in the pathogenesis of pulmonary hypertension associated with shunts
A 32-year-old African American woman presents to her family physician complaining of fevers, fatigue, weight loss, joint pains, night sweats and a rash on her face that extends over the bridge of her nose. She has also had multiple sores in her mouth over the past few weeks. She had a root canal procedure done about 3 months ago without complications. She has no significant past medical history, but has recently had a urinary tract infection. She denies tobacco, alcohol, and illicit drug use. Laboratory evaluation reveals hemolytic anemia. If she were found to have a cardiac lesion, what would be the most likely pathogenetic cause?
A. Bacteremia secondary to recent dental procedure
B. Aberrant flow causing platelet-fibrin thrombus formation secondary to hypercoagulability and malignancy.
C. Bacteremia secondary to a urinary tract infection
D. Immune complex deposition and subsequent inflammation
E. Left atrial mass causing a ball valve-type outflow obstruction
A 32-year-old African American woman presents to her family physician complaining of fevers, fatigue, weight loss, joint pains, night sweats and a rash on her face that extends over the bridge of her nose. She has also had multiple sores in her mouth over the past few weeks. She had a root canal procedure done about 3 months ago without complications. She has no significant past medical history, but has recently had a urinary tract infection. She denies tobacco, alcohol, and illicit drug use. Laboratory evaluation reveals hemolytic anemia. If she were found to have a cardiac lesion, what would be the most likely pathogenetic cause?
A. Bacteremia secondary to recent dental procedure
B. Aberrant flow causing platelet-fibrin thrombus formation secondary to hypercoagulability and malignancy.
C. Bacteremia secondary to a urinary tract infection
D. Immune complex deposition and subsequent inflammation
E. Left atrial mass causing a ball valve-type outflow obstruction
Explanation: This patient’s signs and symptoms point to a diagnosis of systemic lupus erythematosus (SLE). Libman-Sacks endocarditis is a sterile/inflammatory endocarditis that is commonly associated finding with SLE.
Libman-Sacks endocarditis (LSE) is a type of endocarditis that is not caused by bacteria. It is one of the most common cardiac findings associated with lupus, occurring in up to 25% of SLE patients. The mitral valve is most commonly affected, with small vegetations appearing on both sides of the valve. These vegetations can cause mitral valve leaflet thickening; however, this is usually an asymptomatic process.
A. Infective endocarditis from dental procedure in this patient would be subacute and less likely because of the lack of cardiac structural abnormality.
B. Non-bacterial thrombotic endocarditis is usually associated with GI cancer, but the patient’s history does not suggest to have this diagnosis.
C. Given the symptoms, it is not likely to be an acute endocarditis. Similar to option A, subacute endocarditis is less likely given the lack of structural abnormality.
E. Atrial myxomas are benign cardiac tumors that would not be expected to be seen in a patient with lupus.
Learning objectives:
152a Describe the factors predisposing to and the complications of infective endocarditis
152a Describe the key pathological features of both acute and chronic rheumatic heart disease
