NBME 10 and 11. AV block + valves Flashcards
NBME 11. 37Q. A 1-day-old female newborn is examined in the nursery. She was born at term to a 31-year-old primigravid woman following an uncomplicated spontaneous vaginal delivery. The mother has systemic lupus erythematosus; she was asymptomatic during pregnancy, and her only medication was a prenatal vitamin. The patient’s Apgar scores were 9 and 9 at 1 and 5 minutes, respectively. Her temperature is 37°C (98.6°F), pulse is 70/min, respirations are 50/min, and blood pressure is 75/45 mm Hg. Examination shows no abnormalities. An ECG is shown (second degree (Mobitz type II) in a 3:1 ratio of conducted to blocked beat). Which of the following is the most appropriate next step in management?
Insertion of a pacemaker
NBME 11. 37Q. SLE induced AV block. Neonatal lupus is caused by the placental transfer of maternal autoantibodies and can cause heart block in the newborn, as in this patient, as well as cardiomyopathy, aortic dilation, an erythematous rash involving the scalp and periorbital area, photosensitivity, and telangiectasias.
NBME 11. 37Q. SLE induced AV block. Heart block occurs in varying degrees. This patient appears to demonstrate second degree (Mobitz type II) in a 3:1 ratio of conducted to blocked beats. Complete heart block, also called third-degree atrioventricular block, occurs when no sinus impulses are transmitted through the AV conduction pathway resulting in complete dissociation between atrial and ventricular contraction. Ventricular contraction occurs secondary to a junctional rhythm, which can cause bradycardia and decreased cardiac output.
NBME 11. 37Q. SLE induced AV block. Treatment of high grade second-degree, and third-degree block???
Urgent placement of a pacemaker.
NBME 10. 64Q. A 28-year-old primigravid woman at 7 weeks’ gestation is admitted to the hospital because of a2-day history of shortness of breath, palpitations, and light-headedness. Pregnancy had been uncomplicated. She has no history of serious illness, and her only medication is a prenatal vitamin. Two months ago, she visited her parents’ farm in Wisconsin. The patient’s temperature is 37.8°C (100°F), pulse is 38/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Forehead movement is decreased. There is left facial droop, and the patient is unable to close her left eye. An ECG is shown. Which of the following is the most appropriate next step in management?
Administration of ceftriaxone
NBME 10. 64Q. kiti ats. pregn+borelia+av block. why not doxycyline?
contraindicated in pregnancy because of the risk for maternal hepatotoxicity and adverse effects on fetal teeth and bone development. Alternative β-lactam antibiotics should be used instead.
NBME 10. 64Q. kiti ats. pregn+borelia+av block. why not pacemaker? buvo HR 38; ECG p - QRS - p…….p QRS p ….. p?
second-degree atrioventricular (AV) block
Placement of a pacemaker (Choice E) is not currently indicated; however, the patient’s symptomatic bradycardia is concerning and does warrant monitoring in an inpatient setting. Some patients with severe AV block do require temporary pacing, though rhythm disturbances caused by Lyme disease do not typically last more than a few days and permanent pacemaker placement is not generally needed.
NBME 10. 64Q. kiti ats. pregn+borelia+av block.
Later stages of Lyme disease can be characterized by carditis, AV block, facial nerve palsy (which is often bilateral), migratory arthralgias, and, if left untreated, encephalopathy and chronic arthritis. Later stages of Lyme disease that affect the heart or central nervous system are generally treated with parenteral ceftriaxone.
Adverse effects of tetracycline antibiotics include gastrointestinal distress, photosensitivity, and, in children, discoloration of teeth and inhibition of bone growth, which makes it contraindicated in pregnancy.
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NBME 11. 87Q.
An asymptomatic 47-year-old woman comes to the physician for a routine health maintenance examination. She has no history of rheumatic fever. She takes no medications. Her pulse is 70/min, and blood pressure is 150/60 mm Hg. A grade 2/6 decrescendo murmur that begins after S2 is heard at the left sternal border. Which of the following is the most likely diagnosis?
Aortic valve insufficiency
NBME 11. 87Q. kiti ats. crescendo-decrescendo systolic murmur best heard at the upper right sternal border and radiates to the carotid arteries.?
Aortic valve stenosis
It classically occurs secondary to age-related fibrotic and calcific changes of the valve but can occur earlier in life in cases of bicuspid aortic valve or chronic rheumatic disease.
NBME 11. 87Q. kiti ats. holosystolic apical murmur best heard in the left fourth or fifth intercostal space along the midclavicular line and radiates to the left axilla?
Mitral valve regurgitation
It is commonly associated with mitral valve prolapse and prior myocardial infarction.
NBME 11. 87Q. kiti ats.
opening snap followed by a diastolic rumble, which is loudest over the cardiac apex and radiates to the axilla.
Mitral valve stenosis
If severe enough, it can result in left atrial enlargement, cardiogenic pulmonary edema, and arrhythmias such as atrial fibrillation and flutter.
NBME 11. 87Q. kiti ats. discloses a holosystolic murmur best heard in the left lower sternal border?
Tricuspid valve regurgitation
vs
Mitral valve regurgitation (Choice C) presents with a holosystolic apical murmur best heard in the left fourth or fifth intercostal space along the midclavicular line and radiates to the left axilla.
NBME 11. 162Q. MI +
hyperdynamic precordium and new a grade 3/6 holosystolic
murmur after 4 days + BP 82/58 + SpO2 89 proc. Cause?
Chordae tendineae rupture
NBME 11. 162Q.
Chordae tendineae rupture.
Depending on the severity, this can result in acutely decompensated heart failure, and surgical repair may be necessary. The diagnosis is supported by the sudden onset of symptoms, presence of pulmonary rales, and discovery of a new holosystolic murmur on examination.
NBME 11. 162Q. kiti ats. Aortic valvular insufficiency (Choice A) presents with an early diastolic decrescendo murmur best heard in the right second intercostal space. associated with endocarditis, acute rheumatic fever, and aortic root dilation.
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NBME 11. 162Q. kiti ats. Left ventricular free wall rupture Patients typically develop rapid hypotension, shock, and cardiac tamponade.
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