Cardiovascular Flashcards
A 65-year-old man presents to his local GP for a screening ultrasound scan. He has been feeling well and in his usual state of good health. His medical history is notable for mild hypertension and he has a 100-pack-year tobacco history. On palpation, he has a large pulsatile mass just below his umbilicus.
AAA
A 55-year-old man with a history of hypertension (well controlled with medication) and tobacco use presents to his primary care physician with a 2-day history of constant and gnawing hypogastric pain. The pain has been steadily worsening in intensity. He says the pain radiates to his lower back and both groins at times. While he cannot identify any aggravating factors (such as movement), he feels the pain improves with his knees flexed. There is a palpable pulsatile mass just left of midline below the umbilicus. He is immediately referred for definitive management, but during transfer becomes hypotensive and unresponsive.
AAA
A 79-year-old man presents with dyspnoea on exertion for 1 year and lower extremity oedema. As part of a cardiac work-up, the echo shows concentric left ventricular hypertrophy. Cardiac catheterisation shows normal coronary arteries and he is referred for further evaluation of non-cardiac dyspnoea.
Amyloidosis
A 62-year-old man is referred for management of atypical multiple myeloma. He has a mild anaemia of 120 g/L (12 g/dL), a urinary protein loss of 2.2 g/day with a urinary immunofixation showing free lambda light chains. However, the bone marrow shows only 5% plasma cells and does not fulfil criteria for multiple myeloma.
Amyloidosis
A 59-year-old man presents to the emergency department with a sudden onset of excruciating chest pain, which he describes as tearing. There is a history of hypertension. On physical examination, his heart rate is 95 beats per minute. Blood pressure is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.
Aortic dissection
A 55-year-old white man presents with weakness, palpitations, and dyspnoea on exertion. On physical examination, his blood pressure is 148/50 mmHg with a bounding pulse and an early diastolic murmur over the left sternal border. He denies any history of drug abuse, rheumatic fever, or connective tissue disorder. The patient is taking hydrochlorothiazide for high blood pressure. Echocardiography reveals a left ventricular ejection fraction (LVEF) of 55%, left ventricular end-diastolic diameter of 70 mm, and end-systolic diameter of 50 mm.
Aortic regurgitation
A 31-year-old black man presents to clinic for the first time for a routine physical examination. He denies any complaints. On physical examination the only abnormality is a systolic murmur best heard over the second right intercostal space and an early diastolic murmur best heard over the third left sternal border. LVEF is 55% to 60% with mild LVH. Left ventricular end-systolic diameter is 45 mm and aortic root diameter is 3.5 cm.
Aortic regurgitation
A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognises having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels.
Aortic stenosis
A 59-year-old man with a history of smoking and diabetes type 2 presents to his GP with two large, shiny lesions on his left foot that have a ‘punched out’ appearance. They are hairless and cold to touch.
Arterial ulcers
A 70-year-old woman with a history of hypertension, diabetes mellitus, hyperlipidaemia, and prior myocardial infarction presents to the emergency department with palpitations and shortness of breath. These symptoms started 2 days ago. She was diagnosed to have AF with rapid ventricular rate response a year and a half ago, at which time an attempted direct current cardioversion and a trial of sotalol to maintain sinus rhythm and prevent further episodes of AF were unsuccessful. The patient was treated with digoxin and metoprolol to control rate and warfarin to prevent stroke. Current physical examination shows that she is febrile and has an irregularly irregular radial pulse at a rate between 90 and 110 bpm, BP 100/70 mmHg, and respiratory rate of 26 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. The breath sounds are of bronchial character associated with crepitations over left basal lung area.
Atrial fibrillation (chronic)
A 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidaemia presents to the accident and emergency department with the first episode of rapid palpitations, shortness of breath, and discomfort in his chest. These symptoms started acutely and have been present for 4 hours. Physical examination shows an irregularly irregular radial pulse at rate between 90 and 110 bpm, BP 110/70 mmHg, and respiratory rate of 20 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. There are no other abnormalities on examination.
Atrial fibrillation
A 56-year-old woman with a 6- week history of weight loss, anxiety, and insomnia presents with palpitation and dyspnoea. Her pulse rate is irregular at 140 to 150 bpm. Her BP is 95/55 mmHg. She looks thin, frail, and rather anxious and jittery. Her palms are sweaty and have fine tremors. She has a palpable smooth goitre. Examination of the eyes shows bilateral exophthalmoses.
Atrial fibrillation
A 77-year-old man presents with complaints of palpitations and new shortness of breath, especially with exertion. He has a history of rheumatic fever in childhood. He has been told he has a murmur but does not recall having had an echocardiogram. He is otherwise healthy.
Atrial flutter
A 76-year-old man presents with progressive symptoms of dyspnoea and increasing peripheral oedema. He denies palpitations. He has a history of CHF from hypertensive heart disease. He reports that he is taking his medications as directed and has had no recent medication or dietary changes.
Atrial flutter
A 70-year-old woman with a history of hypertension, hyperlipidaemia, 40 pack-years of cigarette smoking, and remote percutaneous transluminal coronary angioplasty is witnessed falling to the ground while brushing her pavement. She has not complained of any preceding symptoms. The emergency medical personnel who respond to the scene find her unconscious, pale, and without a pulse.
Cardiac arrest
A 67-year-old woman presents to her primary care physician complaining of increasing shortness of breath, especially when trying to sleep. She has a history of hypertension and hyperlipidaemia, and is being treated with a beta-blocker and statin therapy. She does not smoke and drinks alcohol in moderation. On examination, her blood pressure is 148/83 mmHg and heart rate is 126 beats per minute. There is an audible S4 and the jugular venous pressure is elevated 3 cm above normal.
Chronic congestive heart failure
A 60-year-old man presents to the accident and emergency department. He reports being progressively short of breath. He has a history of uncontrolled hypertension, non-insulin-dependent diabetes mellitus, and has been a heavy smoker for more than 40 years. He underwent a successful primary angioplasty for a large acute anterior myocardial infarction 2 months ago. His blood pressure is 75/40 mmHg, his heart rate 110 beats per minute, and his respiratory rate 30. He has elevated neck veins and a prominent S3. His ECG shows sinus tachycardia, and a transthoracic echocardiogram performed in the A&E department reveals impaired systolic function, with an ejection fraction of 20%.
Chronic congestive heart failure
A 70-year-old woman complains of increasing exertional dyspnoea for the last 2 days and now has dyspnoea at rest. She has a history of hypertension for the last 5 years and a 35 pack-year smoking history, but no other established illnesses. Current medications are hydrochlorothiazide daily for the last 3 years. She has been prescribed lisinopril but failed to fill the prescription. On examination her BP is 190/90 mmHg, heart rate 104 bpm. There is an audible S4 and the jugular venous pressure is elevated 2 cm above normal. Lung examination reveals fine bibasal crepitations. There is no ankle oedema. Echocardiogram shows an ejection fraction of 60%.
Acute exacerbation of congestive heart failure
A 73-year-old woman with previous history of myocardial infarction presents to the emergency department. She is breathless and finding it difficult to talk in full sentences. On examination she is centrally cyanosed with cool extremities. Her pulse is 110 bpm and systolic BP only just recordable at 80 mmHg. Jugular venous pressure is elevated 3 cm above normal and the cardiac apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest examination. Echocardiogram shows an ejection fraction of 35%
Acute exacerbation of congestive heart failure
A 31-year-old woman presents to A&E with a three month history of shortness of breath and palpitations. As a child she had Doxyrubicin chemotherapy to treat bladder cancer. She also notes her cousin died suddenly of a heart attack whilst playing football. On examination, her JVP is raised and a third heart sound can be heard.
Dilated cardiomyopathy
A 28-year-old man collapses suddenly whilst playing tennis. After being resuscitated he is taken to hospital. He has a jerky carotid pulse and his ECG shows signs of left-axis deviation and left ventricular hypertrophy.
Hypertrophic cardiomyopathy (eg. HOCM)
A 41-year-old man presents to A&E with increasing shortness of breath, bilateral ankle swelling and ascites. On examination, he has a raised JVP and hepatomegaly. His ECG shows low voltage complexes.
Restrictive cardiomyopathy
An otherwise healthy 30-year-old man presents with a several-day history of progressive, severe, retrosternal chest pain that is sharp and pleuritic in nature. The pain is worse on lying down and improved with sitting forward. There is radiation to the neck and shoulders and specifically to the trapezius muscle ridges. The pain is constant and unrelated to exertion. On physical examination, a rubbing sound is heard at end-expiration with the patient leaning forward. The patient also has hepatomegaly and bilateral ankle oedema.
Constrictive pericarditis
A 65-year-old woman presents with unilateral leg pain and swelling of 5 days’ duration. There is a history of hypertension, congestive heart failure, and recent hospitalisation for pneumonia. She had been recuperating at home but on beginning to mobilise and walk, the right leg became painful, tender, and swollen. On examination, the right calf is 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Superficial veins on the right foot are more dilated than on the left and easily visible. The right leg is slightly redder than the left. There is tenderness on palpation in the popliteal fossa behind the right knee.
DVT
A 43-year-old pilot presents for a stress test required by his employer. He states that there is a strong history of premature cardiac disease in his family and 2 of his older brothers are currently being treated for high cholesterol. System review is negative except for some mild shortness of breath with exercise. Examination demonstrates moderate abdominal obesity with a body mass index of 31 kg/m² and waist circumference of 102 cm (40 inches). The remainder of the examination is normal.
Hypercholesterolaemia
A 63-year-old woman with diabetes presents with an episode of retrosternal chest pain and diaphoresis that occurred while walking up stairs earlier that day. Her examination is unremarkable except for blood pressure 156/96 mmHg and abdominal obesity. A recent lipid profile showed triglyceride level 3.8 mmol/L (335 mg/dL), total cholesterol 6.29 mmol/L (243 mg/dL), low-density lipoprotein cholesterol 3.678 mmol/L (142 mg/dL), and high-density lipoprotein cholesterol 0.88 mmol/L (34 mg/dL). Her electrocardiogram shows no acute changes.
Hypertriglyceridaemia
