Darci_USMLE

8/3/2019 Darci_USMLE

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Assessment of Heart Murmurs

Timing

Location

Characteristics

Associated Illnesses/Symptoms

BuzzwordsHeart provides Tender Loving Care for

Arterial Blood


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General Principles

Stenosis = Harsh, turbulent flow

Regurgitation = softer, blowing, gurgle

Systolic = A/P stenosis, M/T regurg, VSD

Diastolic = A regurg or M stenosis


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Mitral Regurgitation

Defined:Retrograde flow from the left ventriclethrough an incompetent mitral valve into the left

atrium

T- holosystolic L- apex, radiates to left axilla

C- soft, high-pitched, blowing

A- MV prolapse, MV myxomatous degeneration,MI, rheumatic heart disease, cardiomyopathy,

endocarditis

B- characteristics, location, radiation


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Aortic Stenosis

Defined:Narrowing of the aortic outflow tractcausing obstruction of flow from the leftventricle into the ascending aorta

T- mid-systolic

L- apex- R 2nd intercostal space, radiates tocarotids

C- harsh, loud, may have associated thrill,

ejection click A- older age, bicuspid aortic valve, rheumatic

fever

B-age of patient, pulsus parvus et tardus,angina, syncope, heart failure


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Possible Exam Question

A 65-year-old man has had congestive heart failure with

increasing pulmonary congestion and edema for several years.He has had increasing peripheral edema involving his lower legsin the last couple of days. His blood pressure is 125/85 mm Hg.He is afebrile. He had been previously healthy all his life withno major illnesses. A serum glucose is 95 mg/dL. His totalserum cholesterol is 185 mg/dL. The serum creatine kinase isnot elevated. The most likely etiology for these findings is:

A. Alcoholic cardiomyopathy

B. Calcified bicuspid aortic valve

C. Tricuspid valve endocarditis

D. Aortic dissection calcification

E. Amyloidosis


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A 65-year-old man has had congestive heart failure with

increasing pulmonary congestion and edema for several years.He has had increasing peripheral edema involving his lower legsin the last couple of days. His blood pressure is 125/85 mm Hg.He is afebrile. He had been previously healthy all his life withno major illnesses. A serum glucose is 95 mg/dL. His totalserum cholesterol is 185 mg/dL. The serum creatine kinase isnot elevated. The most likely etiology for these findings is:

A. Alcoholic cardiomyopathy

B. Calcified bicuspid aortic valve

C. Tricuspid valve endocarditis

D. Aortic dissection calcification

E. Amyloidosis


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VSD

Defined:A congenital abnormality in which bloodflows from high pressure LV low pressure RVthrough a hole

T- holosystolic

L- 3rd, 4th, 5th left interspaces

C- harsh, loud

A- alone or with other abnormalities

B- infant: late cyanosis, holo/pancystolicadult: progressive pulmonary HTN,Eisengengers syndrome


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A term baby is sent home with his mother afterdelivery. The pregnancy was normal. No anomalieswere noted at the time of birth. Five weeks later, themother brings the baby to the clinic because the baby

has difficulty breathing and occasionally turns blue.You hear a pansystolic murmur which is probably dueto a(an):

A. Hypertrophic subaortic stenosis

B. Hypoplastic left heart syndromeC. Coarctation of the aorta

D. Ventricular septal defect

E. Bicuspid aortic valve


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A term baby is sent home with his mother afterdelivery. The pregnancy was normal. No anomalieswere noted at the time of birth. Five weeks later, themother brings the baby to the clinic because the baby

has difficulty breathing and occasionally turns blue.You hear a pansystolic murmur which is probably dueto a(an):

A. Hypertrophic subaortic stenosis

B. Hypoplastic left heart syndromeC. Coarctation of the aorta

D. Ventricular septal defect

E. Bicuspid aortic valve


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A 58-year-old man develops deep venous thrombosis during ahospitalization for prostatectomy. He exhibits decreased mentalstatus with right hemiplegia, and a CT scan of the head suggestsan acute cerebral infarction in the distribution of the left middlecerebral artery. A chest radiograph reveals cardiac enlargement

and prominence of the main pulmonary arteries that suggestspulmonary hypertension. His serum troponin I is


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A 58-year-old man develops deep venous thrombosis during ahospitalization for prostatectomy. He exhibits decreased mentalstatus with right hemiplegia, and a CT scan of the head suggestsan acute cerebral infarction in the distribution of the left middlecerebral artery. A chest radiograph reveals cardiac enlargement

and prominence of the main pulmonary arteries that suggestspulmonary hypertension. His serum troponin I is


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Mitral Prolapse

Defined:A bulging of one or both mitral valveleaflets into the left atrium during systole

T- late systolic

L- apex C- midsystolic click

A- ~5% normal population, asymptomatic, sudden

death

B- midsystolic click, most common valvular

lesion, balloning/floppy valve, Marfans syndrome


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A 19-year-old woman is found to have a cardiac murmurcharacterized by a mid systolic click. An echocardiogramdemonstrates mitral insufficiency with upward displacementof one leaflet. There is aortic root dilation to 4 cm. She has adislocated right ocular crystalline lens. She dies suddenly and

unexpectedly. The medical examiner finds a prolapsed mitralvalve with elongation, thinning, and rupture of chordaetendineae. A mutation involving which of the following genesis most likely to be present in this patient:

A. Beta-myosin

B. CFTRC. FGFR

D. Fibrillin

E. Spectrin


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A 19-year-old woman is found to have a cardiac murmurcharacterized by a mid systolic click. An echocardiogramdemonstrates mitral insufficiency with upward displacementof one leaflet. There is aortic root dilation to 4 cm. She has adislocated right ocular crystalline lens. She dies suddenly and

unexpectedly. The medical examiner finds a prolapsed mitralvalve with elongation, thinning, and rupture of chordaetendineae. A mutation involving which of the following genesis most likely to be present in this patient:

A. Beta-myosin

B. CFTRC. FGFR

D. Fibrillin

E. Spectrin


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Aortic Regurgitation

Defined:Retrograde flow from the aorta intothe left ventricle through incompetentaortic cusps

T- Diastolic L- 2nd-4th left interspaces

C- high-pitched, blowing

A- aortic root degeneration, rheumatic heartdisease, VSD w/aortic valve prolapse (kids)

B- high pulse pressure = bounding pulses


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A 67-year-old man presents to his doctors office for aninsurance physical. During blood pressure measurement,the nurse notes that systolic sounds are heard with the cuffcompletely deflated. The blood pressure is 180/60 mmHg. Physical examination reveals bounding pulses and ahigh-pitched, blowing diastolic murmur, heard best alongthe left sternal border. Which of the following are themost likely diagnosis?

A. Aortic regurgitation

B. Aortic valve obstructionC. Cardiac Tamponade

D. Heart failure

E. Hypovolemia


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A 67-year-old man presents to his doctors office for aninsurance physical. During blood pressure measurement,the nurse notes that systolic sounds are heard with the cuffcompletely deflated. The blood pressure is 180/60 mm Hg.Physical examination reveals bounding pulses and a high-pitched, blowing diastolic murmur, heard best along theleft sternal border. Which of the following are the mostlikely diagnosis?

A. Aortic regurgitation

B. Aortic valve obstructionC. Cardiac Tamponade

D. Heart failure

E. Hypovolemia


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Mitral Stenosis

Defined: Obstruction of flow from left atrium toleft ventricle because of a narrowed mitral orifice

T- Diastolic

L- Apex C-opening snap, low pitched

A- Rheumatic fever

B- hx of childhood rheumatic fever; presents withprogressive dyspnea, pulmonary edema,

hempotysis


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A 30 year-old Hispanic woman reports to her primary care physiciancomplaining ofprogressive dyspnea. She reports she has a two-yearhistory of exertional shortness of breath that has now worsened andaffects her even with modest amounts of activity. Occasionally, a drycough accompanies her dyspnea. Today, she had a mild episode of

hemoptysis, which prompted her visit. She denies fever, chills, orsputum production. Her medical history is significant for a febrileillness with sore throat and joint pain at the age of 15 in Mexico. Onexamination, she is a well-developed female in no acute distress. Acrescendo diastolic rumble is present at the apex of the heart and finecrackles are auscultated at the lung bases. Which of the following is

the most likely diagnosis?A. Mitral stenosis

B. Myocardial infarcion

C. Pneumonia

D. Pulmonary effusion

E. Pulmonary embolus


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A 30 year-old Hispanic woman reports to her primary care physiciancomplaining ofprogressive dyspnea. She reports she has a two-yearhistory of exertional shortness of breath that has now worsened andaffects her even with modest amounts of activity. Occasionally, a drycough accompanies her dyspnea. Today, she had a mild episode ofhemoptysis, which prompted her visit. She denies fever, chills, orsputum production. Her medical history is significant for a febrileillness with sore throat and joint pain at the age of 15 in Mexico. Onexamination, she is a well-developed female in no acute distress. Acrescendo diastolic rumble is present at the apex of the heart and finecrackles are auscultated at the lung bases. Which of the following is

the most likely diagnosis?A. Mitral stenosis

B. Myocardial infarcion

C. Pneumonia

D. Pulmonary effusion

E. Pulmonary embolus


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Patent Ductus Arteriosus

Defined:Failure of the duct betweenpulmonary artery and aorta to close

T- Continuous

L- upper left sternal border

C- machine-like

A- left right shunt, cyanosis

B- infants, machine-like, continuous

murmur


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An x-ray performed on a newborn infant showsenlargement of the left ventricle and left atrium as wellas dilation of the aorta. Echocardiographic studiesdemonstrate volume-overloading of the left ventricle.Cardiac auscultation reveals the presence of acontinuous, machine-like murmur. Which of thefollowing is the most likely diagnosis?

A. Atrial septal defect

B. Patent ductus arteriosusC. Pulmonic stenosis

D. Tetralogy of Fallot

E. Ventricular septal defect


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An x-ray performed on a newborn infant showsenlargement of the left ventricle and left atrium as wellas dilation of the aorta. Echocardiographic studiesdemonstrate volume-overloading of the left ventricle.Cardiac auscultation reveals the presence of a continuousmurmur. Which of the following is the most likelydiagnosis?

A. Atrial septal defect

B. Patent ductus arteriosus

C. Pulmonic stenosisD. Tetralogy of Fallot

E. Ventricular septal defect


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Bonus Question

The infants murmur is most likely related to which of

the following:

A. Blood flowing across the aortic valve

B. Blood flowing from the aorta to the pulmonary artery

C. Blood flowing from the left ventricle to the right

ventricle

D. Blood flowing from the pulmonary artery to the aorta

E. Blood flowing from the right ventricle to the left

ventricle


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Bonus Question

The infants murmur is most likely related to which of

the following:

A. Blood flowing across the aortic valve

B. Blood flowing from the aorta to the pulmonary artery

C. Blood flowing from the left ventricle to the right

ventricle

D. Blood flowing from the pulmonary artery to the aorta

E. Blood flowing from the right ventricle to the left

ventricle


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Congestive Heart Failure

Cause Effect

LV output does not w/exerciseDOE

End Diastolic VolumeCardiac Dilation

LV failure pulmonary venous pressurefluid transudationPulmonary Edema, PND

venous return exacerbates pulmonary vascular

congestionOrthopnea


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central venous pressure resistance to portal

flowHepatomegaly

(nutmeg liver)

RV failure venous

pressure fluid

transudationAnkle,sacral edema

Congestive Heart Failure


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Cardiac Tumors

Most common tumor = Metastasis

I

Most common 1 adult tumor = MyxomaBall-valve obstruction in Left Atrium (LA

Dodgers)

Most common 1 pediatric tumor =rhabdomyoma

Associated with tuberous sclerosis


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An adult presents to a physician because of repeatedepisodes of fainting. ECG fails to disclose andarrhythmia. Echocardiogram shows a mass in the leftatrium that is producing intermittent obstruction of flow.Which of the following would most likely be seen on

microscopic examination of the resected mass?

A. Benign myxoid tumor

B. Benign tumor with gland formation

C. Benign tumor with striated muscle differentiation

D. Malignant tumor with gland formation

E. Malignant tumor with striated muscle differentiation


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An adult presents to a physician because of repeatedepisodes of fainting. ECG fails to disclose andarrhythmia. Echocardiogram shows a mass in the leftatrium that is producing intermittent obstruction of flow.Which of the following would most likely be seen on

microscopic examination of the resected mass?

A. Benign myxoid tumor

B. Benign tumor with gland formation

C. Benign tumor with striated muscle differentiation

D. Malignant tumor with gland formation

E. Malignant tumor with striated muscle differentiation


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Embolus Types

Fat- long bone fracturesand liposuction

Air

Thrombus

Bacteria

Amniotic Fluidpostpartum DIC

Tumor

Today the

vasculature,tomorrowthe world!


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Cardiac Tamponade

Tamponade:closure or blockage (as of awound or body cavity)

Tampon = stops fluid flow

Compression of heart by fluid in thepericardium CO, pressure equilibration

PE: hypotension, JVD ( venous pressure),heart sounds distant or muffled

Other findings: electrical alternans of EKG,pulsus paradoxus (variation with respiration)


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Deep Venous Thrombosis

Virchow = VirtuousCow

Holy Trinity:

Stasis Hypercoagulability

Endothelial Damage


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Bacterial Endocarditis

Meet Tarzan and Jane

For Tarzan, love at

first sight (rapid onset)

Jane is a golden girl(S. aureus)

Would like to take her

into the vegetation and

get to know her better


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Jane is not nice to Tarzan

Thinks Tarzan is not too

bright, doesnt have good

hygiene (green teeth =

viridans streptococcus)

Ends up breaking his heart

(chordae rupture,

supporative pericarditis)

Tarzan feels unmitigated

despair (mitral valve)


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Fever Roths spots

Oslers nodes

Murmur Janeway lesions

Anemia

Nail-bed hemorrhages Emboli

It gets so bad, Tarzaneventually turns to IV

drugs

Ends up with gettingendocarditis in his

tricuspid valve


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Non-Infectious Endocarditis

2 to metastasis orrenal failure(marantic/thromboticendocarditis)

Libman-Sacksendocarditis

vegetations on bothsides of valve mitral

valve stenosis; do notembolize

Associated with lupus:SLE causes LSE

"What is it? Meningitis? Scoliosis?? Lupus??? Is it Lupus????"


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A 27-year-old man has become severely ill over the pastthree days, with fever and malaise. On admission to theemergency room, he has a heart rate of 105/minute,respiratory rate of 24, blood pressure of 80/40 mm Hg,and temperature 39.1 C. A grade IV/VI diastolic murmur

is audible. He has small hemorrhages visible on nailbeds. His spleen tip is palpable. The process that isLEAST likely to predispose this illness is:

A. Ventricular septal defect

B. Rheumatic heart diseaseC. Cardiac amyloidosis

D. Intravenous drug use

E. Prosthetic valve placement


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A 27-year-old man has become severely ill over the pastthree days, with fever and malaise. On admission to theemergency room, he has a heart rate of 105/minute,respiratory rate of 24, blood pressure of 80/40 mm Hg,and temperature 39.1 C. A grade IV/VI diastolic murmur

is audible. He has small hemorrhages visible on nailbeds. His spleen tip is palpable. The process that isLEAST likely to predispose this illness is:

A. Ventricular septal defect

B. Rheumatic heart diseaseC. Cardiac amyloidosis

D. Intravenous drug use

E. Prosthetic valve placement


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Rheumatic Fever

Consequence of infection with group A b-hemolytic streptococci

Late sequelae includes valvular disease

(Romantic Fever):

I M.A.T.

Mitral > Aortic > Tricuspid


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Rheumatic Fever

Fever

Erythema marginatum

Valvular damage

ESR

Red-hot joints (polyarthritis)

Subcutaneous nodules

St. Vitus Dance (chorea)

Strep antibody titer (ASO )

Aschoff Bodies Granulomas with

giant cells

Anitschkows cells

Activated

histiocytes

Two RHussians

with RHumaticheart disease


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Rheumatic Fever

John Travolta careerslump

Makes sequel toSaturday Night Fever

calledRheumatic Fever John gets

Fever

Myocarditis

Joint swelling(Polyarthritis)

Chorea (uncontrolleddance-like movements of

extremities

St. Vitus Dance


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A 42-year-old woman has increasing congestiveheart failure. As a child she suffered recurrentbouts of pharyngitis with group A beta hemolyticstreptococcal infections. The cardiac valves most

likely to be affected are:A. Aortic and tricuspid

B. Mitral and pulmonic

C. Aortic and pulmonic

D. Tricuspid and pulmonic

E. Mitral and aortic


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A 42-year-old woman has increasing congestiveheart failure. As a child she suffered recurrentbouts of pharyngitis with group A beta hemolyticstreptococcal infections. The cardiac valves most

likely to be affected are:A. Aortic and tricuspid

B. Mitral and pulmonic

C. Aortic and pulmonic

D. Tricuspid and pulmonic

E. Mitral and aortic


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Pericarditis

Serous SLE,

Rhuematoid arthritis

Uremia

Infection (serious)

Fibrinous

MI (death of muscle

fibers) Rhuematic fever

Uremia

Hemorrhagic (Invasive!) TB (thinkhemoptysis)

Malignancy (aggressive)

May resolve without

scarring

May progress to chronic

adhesive or constrictivepericarditis


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Syphilitic Heart Disease

3 syphillis- long standing

Destruction ofvasa vasorum

Dilation of aortic root

without atheroscleroticlesion = syphilitic aneurysm

Calcification of ascendingarch and aortic root

Tree-barking- post-inflammatory scarring of theaorta


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Examination of an autopsy specimen from aMexican immigrant demonstrates a heart withmassive dilation of the aortic root and adjacentaortic arch. Opening the aorta reveals a

distinctive wrinkling of the intimal surface. If ahistological section through the aortic wall ismade, which of the following will be seen?

A. A heavy eosinophilic infiltrate

B. Fibrinoid necrosis with a neutrophilic infiltrationC. Focal fragmentation of elastic elements

D. Obliterative endarteritis of vasa vasorum

E. Ring-like calcification of the vessel media


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Examination of an autopsy specimen from aMexican immigrant demonstrates a heart withmassive dilation of the aortic root and adjacentaortic arch. Opening the aorta reveals a

distinctive wrinkling of the intimal surface. If ahistological section through the aortic wall ismade, which of the following will be seen?

A. A heavy eosinophilic infiltrate

B. Fibrinoid necrosis with a neutrophilic infiltrationC. Focal fragmentation of elastic elements

D. Obliterative endarteritis of vasa vasorum

E. Ring-like calcification of the vessel media


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Thromboangitis Obliterans:

Buergers Disease

Idiopathic, associated withsmoking

Segmental, thrombosing

vasculitis of small-medium

peripheral arteries and veins

Symptoms: claudication,

cold sensitivity (Raynauds

phenomenon), severe pain,gangrene

Symptoms may improve if

patient quits smoking

If only I had

hands, I

would eat a

Buerger!


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Takayasus Arteritis

Pulseless disease Granulomatous

thickening ofaorticarch and proximal

great veins Associated with

ESR

Primarily affects

Asian females


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Takayasus Arteritis

Fever

Arthritis

Night sweats

MYalgia

SKIN nodules

Ocular disturbances

Weak pulse in upperextremity

T l A i i


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Temporal Arteritis

(Giant Cell Arteritis) Medium and small arteries, usually

branches of carotid artery (temporal artery)

Giant cells

Presentation: older female, unilateralheadache, jaw claudication, impaired vision

Blindness is possible complication

Responds to steroids

Elevated ESR


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A 74-year-old woman has had increasingly severe, throbbingheadaches for several months, centered on the right. She sees herphysician, who records vital signs of T 36.1 R 22 P 82 and BP130/85 mm Hg. There is a palpable tender cord-like area over herright temple. Her heart rate is regular with no murmurs, gallops, orrubs. Pulses are equal and full in all extremities. A biopsy of this

lesion is obtained next, and histologic examination reveals amuscular artery with lumenal narrowing and medial inflammationwith lymphocytes, macrophages, and occasional giant cells. Sheimproves with a course of high-dose corticosteroid therapy. Which ofthe following laboratory test findings is most likely to be presentwith this disease:

A. Erythrocyte sedimentation rate of 110 mm/hr

B. Rheumatoid factor titer of 80 IU/mL

C. HDL cholesterol of 15 mg/dL

D. Anti-double stranded DNA titer of 1:1024

E. pANCA titer of 1:160


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A 74-year-old woman has had increasingly severe, throbbingheadaches for several months, centered on the right. She sees herphysician, who records vital signs of T 36.1 R 22 P 82 and BP130/85 mm Hg. There is a palpable tender cord-like area over herright temple. Her heart rate is regular with no murmurs, gallops, orrubs. Pulses are equal and full in all extremities. A biopsy of this

lesion is obtained next, and histologic examination reveals amuscular artery with lumenal narrowing and medial inflammationwith lymphocytes, macrophages, and occasional giant cells. Sheimproves with a course of high-dose corticosteroid therapy. Which ofthe following laboratory test findings is most likely to be presentwith this disease:

A. Erythrocyte sedimentation rate of 110 mm/hr

B. Rheumatoid factor titer of 80 IU/mL

C. HDL cholesterol of 15 mg/dL

D. Anti-double stranded DNA titer of 1:1024

E. pANCA titer of 1:160


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