Internal Medicine Board Review Cardiology Mike McMullan, M.D.,
FACC July 17, 2014 Slide 2 Internal Medicine Examination Cardiology
is the largest section of the reviewCardiology is the largest
section of the review Why is this?Why is this? Cardiology is the
largest section of the boards 40% more than the next closest topic
14% of exam, pulmonary is next at 10% Cardiovascular disease
affects more people than any other disease process Almost half of
your family, friends, neighbors, and patients will eventually die
from heart disease Slide 3 Cardiology Topic Breakdown Slide 4 Slide
5 My Assignment To cover these areasTo cover these areas Physical
examination Valvular disease Congenital heart disease Pericardial
disease Endocarditis/SBE prophylaxis In order to answerIn order to
answer 0 questions 2-5 questions 0-1 questions 1-4 questions 0-1
questions _____________ 3-11 questions 3-11 questions But the truth
of the matter is that physical examination will encompass all 32
questions! Slide 6 Breaking It Down My Method Focused board
oriented pearls of frequently-tested disease processes (This is NOT
a comprehensive discussion of each topic!)Focused board oriented
pearls of frequently-tested disease processes (This is NOT a
comprehensive discussion of each topic!) Broken down by general
topics Highlight common scenarios within each topic Symptoms
Physical findings Diagnostic tests Management Common word
associationsCommon word associations Slide 7 Breaking It Down
Physical examinationPhysical examination Knowing the basics will
help you figure out questions Will often ask for the diagnostic
test (echo) rather than the diagnosis (aortic stenosis) Be aware of
normal findings that require no further w/u e.g. innocent flow
murmurs, venous hum Recognize cardiac clues to systemic diseases
e.g. rapid atrial fibrillation with a scratchy murmur
hyperthyroidism MeansLerman scratch Slide 8 The Basics Slide 9
Where does S1 occur? A.a B.b C.c D.d E.e F.f S1 Slide 10 Where does
S2 occur? A.a B.b C.c D.d E.e F.f S2 Slide 11 Where does S4 occur?
A.a B.b C.c D.d E.e F.f S4 Slide 12 The Basics 4 heart sounds4
heart sounds S1 closure of mitral/tricuspid valves S2 closure of
aortic/pulmonic valves S3 rapid ventricular filling with rapid flow
deceleration May be normal in pts < 40 y/o Often seen in CMP and
ventricular failure S4 atrial contraction against a stiff ventricle
HTN HCM Aortic stenosis Slide 13 Which of these sounds is lost in a
patient with atrial fibrillation? A.S1 B.S2 C.S3 D.S4 Slide 14 The
Basics 3 additional heart sounds3 additional heart sounds Click
(occur with valve closure) Usually MVP Rarely tricuspid click in
Ebsteins anomaly Opening snap (occur with valve opening) Usually
right after S2 - mitral stenosis Can occur at beginning of systole
congenital aortic stenosis and is more often called ejection sound
Rub (occur with cardiac motion) Up to 3 components Atrial systole
Ventricular systole Ventricular diastole 2 of 3 components are in
diastole Slide 15 The Basics 3 types of mumurs3 types of mumurs
Systolic Systolic ejection=mid-systolic=crescendo-decrescendo
Pansystolic=holosystolic Late systolic associated with click = MVP!
Diastolic Early high-pitched decrescendo Aortic or pulmonic
regurgitation Low pitched rumble throughout diastole Mitral or
tricuspid stenosis Continuous Patent ductus arteriosus AP window
Shunt or fistula Slide 16 Basic Murmurs S1 S2 S1 S2 S4 S3 OS ES
Slide 17 Venous Waveforms in a Nutshell Slide 18 Ventricular
systole Ventricular systole Slide 19 Large v Waves Slide 20 Whats
the diagnosis? A.Aortic stenosis B.Aortic regurgitation C.Mitral
regurgitation D.Tricuspid regurgitation Slide 21 Whats the
diagnosis? A.Aortic stenosis B.Aortic regurgitation C.Mitral
regurgitation D.Tricuspid regurgitation Slide 22 Whats the
diagnosis? A.Mitral regurgitation B.Mitral stenosis C.Aortic
regurgitation D.Aortic stenosis 40 30 20 10 0 x LV y LA mmHg Slide
23 Whats the diagnosis? A.Aortic stenosis B.HCM with obstruction
C.MVP D.Aortic regurgitation Pulsus bisferiens Brockenbrough sign
Slide 24 Slide 25 Normal Findings Innocent murmursInnocent murmurs
Grade 1-2 (mid)systolic ejection murmurs NEVER Grade 3 or more
Pansystolic Diastolic Continuous Other abnormal sounds e.g. fixed
split S2 Venous humsVenous hums High flow states e.g. anemia Goes
away when lays down Slide 26 Breaking It Down Pericardial disease
(1-4 questions)Pericardial disease (1-4 questions) Cardiac
tamponade Constrictive pericarditis Acute pericarditis Slide 27
Cardiac Tamponade Scenarios trauma and breast cancer are the two
biggies on boards, also lupus and renal failure, occasionally viral
pericarditis (rarely aortic dissection)Scenarios trauma and breast
cancer are the two biggies on boards, also lupus and renal failure,
occasionally viral pericarditis (rarely aortic dissection)
Diagnosis Becks triad (hypotension and elevated neck veins with
quiet precordium), pulsus paradoxus, electrical alternansDiagnosis
Becks triad (hypotension and elevated neck veins with quiet
precordium), pulsus paradoxus, electrical alternans Tests - Swan
hemodynamics with equalization of all diastolic pressures and slow
y descent, echoTests - Swan hemodynamics with equalization of all
diastolic pressures and slow y descent, echo Mgt
pericardiocentesisMgt pericardiocentesis Slide 28 Slide 29 RA
Pressure in Tamponade Slide 30 Slide 31 Constrictive Pericarditis
Scenarios post-radiation for lymphoma, CTD, TBScenarios
post-radiation for lymphoma, CTD, TB Diagnosis dyspnea, elevated
JVP, Kussmauls sign, edema, pericardial knockDiagnosis dyspnea,
elevated JVP, Kussmauls sign, edema, pericardial knock Tests echo,
CT or MRI, cath with prominent x and y descents, equalization of
diastolic pressures with square root signTests echo, CT or MRI,
cath with prominent x and y descents, equalization of diastolic
pressures with square root sign Mgt pericardial strippingMgt
pericardial stripping Slide 32 Constrictive Pericarditis
Constrictive Pericarditis Kussmauls sign Slide 33 Slide 34 125 0 LA
Equalization of Diastolic Pressures 2525 50 75 100 RA RV LV
Constrictive Pericarditis X Y Y>X Square-root sign RVEDP >
1/3 RVSP Slide 35 Acute Pericarditis Scenarios usually post-viral
syndromeScenarios usually post-viral syndrome Diagnosis pleuritic
chest pain, feels better sitting up and leaning forward,
pericardial friction rubDiagnosis pleuritic chest pain, feels
better sitting up and leaning forward, pericardial friction rub
Tests EKG with diffuse ST elevation, elevated ESR, CRP and/or
biomarkersTests EKG with diffuse ST elevation, elevated ESR, CRP
and/or biomarkers Mgt NSAIDsMgt NSAIDs Ibuprofen 600-800 mg TID or
ASA 650-1000 mg TID or Indomethacin 50 mg TID for 7-10 days
Colchicine 0.5 0.6 mg BIDColchicine 0.5 0.6 mg BID Refractory
prednisone plus colchicineRefractory prednisone plus colchicine
Slide 36 Slide 37 Slide 38 Breaking It Down Congenital heart
disease (0-1 questions)Congenital heart disease (0-1 questions) ASD
recognize the EKG VSD almost always no treatment necessary in
adults PDA continuous murmur Coarctation of aorta secondary HTN,
differential BPs If cyanotic pt (unlikely), probably Tetralogy of
Fallot Pregnancy tolerated in all patients except pulmonary HTN and
cardiomyopathies Slide 39 Atrial Septal Defect 4 types but only
need to know ostium secundum for boards4 types but only need to
know ostium secundum for boards Scenario young adult with murmur or
palpitationsScenario young adult with murmur or palpitations
Diagnosis fixed split S2, 2/6 SEM at LUSBDiagnosis fixed split S2,
2/6 SEM at LUSB Tests EKG with incomplete RBBB and RAD, echo, cath
with shunt runTests EKG with incomplete RBBB and RAD, echo, cath
with shunt run Mgt closure (percutaneously or surgically) for shunt
> 1.5:1Mgt closure (percutaneously or surgically) for shunt >
1.5:1 No SBE prophylaxis recommended low riskNo SBE prophylaxis
recommended low risk Slide 40 Atrial Septal Defect Slide 41 ASD EKG
Slide 42 ASD TEE Slide 43 ASD Occluder Slide 44 VSD Scenario
asymptomatic young adult referred for murmurScenario asymptomatic
young adult referred for murmur Diagnosis loud grade 5/6
pansystolic murmur at LSBDiagnosis loud grade 5/6 pansystolic
murmur at LSB Test echoTest echo Mgt closure not typically needed
for adults, no longer need SBE prophylaxis by guidelinesMgt closure
not typically needed for adults, no longer need SBE prophylaxis by
guidelines Slide 45 Ventricular Septal Defect Slide 46 Slide 47
Slide 48 PDA Scenario teen or young adult referred for
murmurScenario teen or young adult referred for murmur Diagnosis
usually asymptomatic, continuous murmur LSBDiagnosis usually
asymptomatic, continuous murmur LSB Tests echoTests echo Mgt
closure if murmur noted or left ventricular enlargement or
pulmonary HTN, small ones without murmur do not need to be closed,
no longer need SBE prophylaxisMgt closure if murmur noted or left
ventricular enlargement or pulmonary HTN, small ones without murmur
do not need to be closed, no longer need SBE prophylaxis Slide 49
Patent Ductus Arteriosus Slide 50 Slide 51 Coarctation of Aorta
Great IM board question since it is a secondary cause of HTNGreat
IM board question since it is a secondary cause of HTN Scenario
young adult with HTN, association with Turners syndromeScenario
young adult with HTN, association with Turners syndrome Diagnosis
BP in arms vs legs, radiofemoral pulse delay, 2/6 SEM LSB, may have
aortic ejection click with bicuspid aortic valveDiagnosis BP in
arms vs legs, radiofemoral pulse delay, 2/6 SEM LSB, may have
aortic ejection click with bicuspid aortic valve Tests CXR with
figure 3 sign and rib notching, echo, CT angio or MRATests CXR with
figure 3 sign and rib notching, echo, CT angio or MRA Mgt surgical
repair, less commonly stentMgt surgical repair, less commonly stent
Slide 52 Coarctation of Aorta Slide 53 Coarctation CXR Slide 54
Slide 55 Cyanotic Lesions Not likely for an IM boardNot likely for
an IM board Tetralogy most common young person with cyanosis and
squattingTetralogy most common young person with cyanosis and
squatting Eisenmengers (secondary pulm HTN with conversion to
right-to-left shunt) most commonly occurs with VSDEisenmengers
(secondary pulm HTN with conversion to right-to-left shunt) most
commonly occurs with VSD Ebsteins may present as cyanosis in adult,
usually with palpitations due to right-sided accessory pathway,
marked RAE on EKG and echoEbsteins may present as cyanosis in
adult, usually with palpitations due to right-sided accessory
pathway, marked RAE on EKG and echo Slide 56 Tetralogy of Fallot
Slide 57 Pregnancy and Heart Disease Lots of pregnant women on the
boards not many with heart diseaseLots of pregnant women on the
boards not many with heart disease Cardiac lesions affecting
pregnancyCardiac lesions affecting pregnancy Pulmonary HTN Cyanotic
lesions (uncorrected) Stenotic valve lesions CMP Recommend vaginal
delivery with facilitated second stageRecommend vaginal delivery
with facilitated second stage Peripartum CMP may occur last 3
months of pregnancy or first 6 months after deliveryPeripartum CMP
may occur last 3 months of pregnancy or first 6 months after
delivery Marfans and coarctation are at higher risk for aortic
rupture during surgeryMarfans and coarctation are at higher risk
for aortic rupture during surgery Slide 58 Pregnancy and Heart
Disease High riskHigh risk Eisenmengers syndrome Severe pulmonary
HTN Severe aortic stenosis/LVOT obstruction Coarctation of the
aorta with obstruction Marfans syndrome with aortic root > 43 mm
Symptomatic systemic ventricular dysfunction with EF < 40% Need
referral to high risk OB center with cardiology collaborationNeed
referral to high risk OB center with cardiology collaboration Lower
risk lesions can typically have normal pregnancy and deliveryLower
risk lesions can typically have normal pregnancy and delivery
CARPREG scoreCARPREG score Poor functional status (NYHA >2) or
cyanosis Systemic ventricular dysfunction Left heart obstruction
History of heart failure, stroke, or arrhythmia Slide 59 Risk of
CHD in Offspring of Parents with CHD Typically 3-12%Typically 3-12%
Can be up to 50% (Marfans syndrome)Can be up to 50% (Marfans
syndrome) Fetal ultrasonography recommended @18 weeksFetal
ultrasonography recommended @18 weeks Slide 60 Breaking It Down
Valvular heart disease (2-5 questions)Valvular heart disease (2-5
questions) Aortic stenosis elderly vs younger Aortic regurgitation
Marfans or endocarditis MVP maneuvers, SBE prophylaxis HCM sudden
death in an athlete, maneuvers Mitral stenosis rheumatic heart
disease Tricuspid stenosis with carcinoid patient Tricuspid
regurgitation in a patient with right heart failure Slide 61 Aortic
Stenosis Scenarios young to middle aged adult with bicuspid valve,
older adult (> 70 y/o) with tricuspid valveScenarios young to
middle aged adult with bicuspid valve, older adult (> 70 y/o)
with tricuspid valve DiagnosisDiagnosis Symptoms are chest pain,
syncope, CHF PE shows 3-4/6 SEM at RUSB radiating to carotids,
pulsus parvus et tardus (weak and delayed upstrokes) Tests echo,
cath only as pre-op for CADTests echo, cath only as pre-op for CAD
Mgt surgery, balloon valvuloplasty is only palliative and
short-lived, TAVR new option only for inoperable or extreme high
risk at present probably too early for boards right nowMgt surgery,
balloon valvuloplasty is only palliative and short-lived, TAVR new
option only for inoperable or extreme high risk at present probably
too early for boards right now Slide 62 Aortic Regurgitation
Scenario Marfans syndrome, endocarditisScenario Marfans syndrome,
endocarditis Diagnosis shortness of breath, early high-pitched
decrescendo diastolic murmur at left or right upper sternal border,
wide pulse pressure, brisk pulsesDiagnosis shortness of breath,
early high-pitched decrescendo diastolic murmur at left or right
upper sternal border, wide pulse pressure, brisk pulses Test
echoTest echo Mgt afterload reduction with ACE inhibitor or
nifedipine, valve replacement for EF 55mmMgt afterload reduction
with ACE inhibitor or nifedipine, valve replacement for EF 55mm
Slide 63 MVP Favorite board questionFavorite board question
Scenario young woman with palpitations, chest painScenario young
woman with palpitations, chest pain Diagnosis mid-systolic click
with late systolic murmur, increases with ValsalvaDiagnosis
mid-systolic click with late systolic murmur, increases with
Valsalva Test echoTest echo Mgt beta blocker for symptoms, SBE
prophylaxis no longer recommended!, valve repair only for severe
regurgitation +/- atrial fibrillation or pulmonary HTNMgt beta
blocker for symptoms, SBE prophylaxis no longer recommended!, valve
repair only for severe regurgitation +/- atrial fibrillation or
pulmonary HTN Slide 64 MVP Slide 65 Hypertrophic Cardiomyopathy
Favorite board questionFavorite board question Scenario young
athlete with syncope or aborted sudden death, SOB, diastolic heart
failureScenario young athlete with syncope or aborted sudden death,
SOB, diastolic heart failure Diagnosis SEM at RUSB which increases
with Valsalva, brisk carotid upstrokes, S4, pulsus
bisferiensDiagnosis SEM at RUSB which increases with Valsalva,
brisk carotid upstrokes, S4, pulsus bisferiens Test EKG with LVH
and T wave inversion, echoTest EKG with LVH and T wave inversion,
echo Mgt beta blockers and calcium channel blockers, surgical or
percutaneous myectomy, ICD placement if high risk for sudden death,
no competitive athletics except golf and bowling, screening of
first- and second-degree relativesMgt beta blockers and calcium
channel blockers, surgical or percutaneous myectomy, ICD placement
if high risk for sudden death, no competitive athletics except golf
and bowling, screening of first- and second-degree relatives Slide
66 HCM Slide 67 Slide 68 HCM EKG Slide 69 Differentiating Aortic
Stenosis from Hypertrophic Cardiomyopathy SameSame Both may present
with syncope Both have a harsh SEM radiating to the carotids
DifferentDifferent HCM usually younger than AS Carotid upstrokes
are brisk with HCM, diminished with AS Murmur gets louder with
Valsalva with HCM, softer with Valsalva with AS Slide 70 Mitral
Stenosis Yet another favorite board questionYet another favorite
board question Scenario woman with history of rheumatic heart
diseaseScenario woman with history of rheumatic heart disease
Diagnosis DOE, palpitations, PND, diastolic rumble with loud S1 and
opening snap just after S2, small PMI, palpable P2, ralesDiagnosis
DOE, palpitations, PND, diastolic rumble with loud S1 and opening
snap just after S2, small PMI, palpable P2, rales Tests echo, TEE
to grade valveTests echo, TEE to grade valve Mgt slow heart rate to
improve diastolic filling time beta blockers, SBE prophylaxis no
longer required, balloon valvuloplasty is the first line procedure
for these pts (as opposed to AS)Mgt slow heart rate to improve
diastolic filling time beta blockers, SBE prophylaxis no longer
required, balloon valvuloplasty is the first line procedure for
these pts (as opposed to AS) Slide 71 Tricuspid Stenosis Not a
likely questionNot a likely question Same murmur as mitral stenosis
but at left sternal border rather than apexSame murmur as mitral
stenosis but at left sternal border rather than apex Present with
right heart failure rather than DOE and ralesPresent with right
heart failure rather than DOE and rales Seen in association with
carcinoid and with prior use of Fen-PhenSeen in association with
carcinoid and with prior use of Fen-Phen Slide 72 Tricuspid
Regurgitation Not a likely test question, but may see a case of
pulm HTN with TR and also PRNot a likely test question, but may see
a case of pulm HTN with TR and also PR Scenario young woman with
severe SOB, hypoxia, and right heart failure edema, ascites,
elevated JVP, large v wave, pulsatile liverScenario young woman
with severe SOB, hypoxia, and right heart failure edema, ascites,
elevated JVP, large v wave, pulsatile liver Diagnosis echo, right
heart cath, CTA must rule out other etiologies CTD, congenital
heart disease, recurrent PEDiagnosis echo, right heart cath, CTA
must rule out other etiologies CTD, congenital heart disease,
recurrent PE Mgt pulm HTN has poor prognosis if no reversible
cause, O2, calcium blockers, Coumadin, prostacyclin analogs
(epoprostenol), endothelin receptor antagonists (bosentan),
phosphodiesterase-5 inhibitors (sildenafil), lung
transplantationMgt pulm HTN has poor prognosis if no reversible
cause, O2, calcium blockers, Coumadin, prostacyclin analogs
(epoprostenol), endothelin receptor antagonists (bosentan),
phosphodiesterase-5 inhibitors (sildenafil), lung transplantation
Slide 73 Endocarditis Guidelines Updated 2008 No Class I
indications for endocarditis prophylaxisNo Class I indications for
endocarditis prophylaxis Class IIA recommendationsClass IIA
recommendations Antibiotic prophylaxis is reasonable for dental
procedures for patients with Prosthetic cardiac valve or material
used in valve repair Previous endocarditis Congenital heart disease
Unrepaired cyanotic disease, including palliative shunts/conduits
Completely repaired CHD for the first six months after correction
Repaired CHD with residual defects at site of prosthesis Cardiac
transplant with valvular heart disease No prophylaxis for GI or GU
procedures Slide 74 SBE Prophylaxis Know prophylaxis regimenKnow
prophylaxis regimen Amoxicillin 2.0 g orally 1 hour before
procedure Know what to use in a PCN allergic patient!Know what to
use in a PCN allergic patient! Clindamycin 600 mg orally 1 hour
before procedure Keflex 2.0 g orally 1 hour before procedure
Zithromax 500 mg orally 1 hour before procedure Slide 75
Endocarditis Scenario think about it in a pt with multisystem
involvement, fever, chills, skin lesions, recent dental work or
surgery, murmur also with an IV drug user with multiple lung
lesionsScenario think about it in a pt with multisystem
involvement, fever, chills, skin lesions, recent dental work or
surgery, murmur also with an IV drug user with multiple lung
lesions Diagnosis clinical picture, fever, regurgitant murmur,
splenomegaly, Janeway lesions, Oslers nodes, Roths spots, anemia,
leukocytosis, elevated ESR and CRP, glomerulonephritisDiagnosis
clinical picture, fever, regurgitant murmur, splenomegaly, Janeway
lesions, Oslers nodes, Roths spots, anemia, leukocytosis, elevated
ESR and CRP, glomerulonephritis Tests blood cultures are mainstay
of diagnosis, echo/TEETests blood cultures are mainstay of
diagnosis, echo/TEE Mgt IV antibioticsMgt IV antibiotics Empiric
therapy Vancomycin after 2-3 sets of blood cultures drawn Guide
further therapy based on organism/sensitivities PCN G or Rocephin
for 4 weeks PCN G + Gentamicin for 2 weeks Common organism Viridans
group streptococciCommon organism Viridans group streptococci
Unusual organism associationsUnusual organism associations Strep
gallolyticus (formerly Strep bovis) Associated with colon cancer
Needs colonscopy Slide 76 Slide 77 Slide 78 Slide 79 Slide 80 The
Bottom Line Recognize word associationsRecognize word associations
Irregularly irregular Mid-systolic click Pulsus paradoxus Pulsus
alternans Electrical alternans Pulsus parvus et tardus Kussmauls
sign Large v waves Prominent x and y descents Fixed splitting of S2
Paradoxical splitting of S2 Wide physiologic splitting of S2 Slide
81 The Bottom Line Recognize word associationsRecognize word
associations Pericardial knock Pericardial rub Continuous murmur
Pansystolic murmur Early high pitched diastolic murmur Low pitched
diastolic rumble Elevated neck veins with clear lung fields
Elevated neck veins with hypotension and quiet precordium Murmur
increases with Valsalva Slide 82 80 year old woman presents with
syncope, on exam has weak carotid upstrokes, a normal S1 with a
diminished S2, and a grade III/VI systolic ejection murmur at the
RUSB radiating to the carotids. A.Bicuspid aortic valve stenosis
B.Tricuspid aortic valve stenosis C.Hypertrophic cardiomyopathy
D.VSD Slide 83 40 year old man with Marfans syndrome, a blood
pressure of 150/50, brisk pulses throughout, and an early
high-pitched diastolic murmur heard best at the RUSB A.Hypertrophic
cardiomyopathy B.Mitral stenosis C.Aortic regurgitation D.Pulmonic
regurgitation Slide 84 30 year old woman who presents with
palpitations, on exam has a normal S1 and S2, a midsystolic click,
and a late systolic murmur that occurs earlier (becomes longer
and/or louder) with Valsalva maneuver A.VSD B.Hypertrophic
cardiomyopathy C.Mitral regurgitation D.Mitral valve prolapse Slide
85 20 year old basketball player referred for episode of syncope,
noted to have brisk carotid upstrokes, a normal S1 and S2 with an
S4 gallop, and a grade II/VI systolic ejection murmur at the LSB
which becomes louder with Valsalva maneuver A.Bicuspid aortic
stenosis B.Tricuspid aortic stenosis C.Hypertrophic cardiomyopathy
D.Mitral valve prolapse Slide 86 Maneuvers Valsalva and standing
decrease ALL murmurs except Valsalva and standing decrease ALL
murmurs except Hypertrophic cardiomyopathy Mitral valve prolapse
Therefore Valsalva and standing increase the murmur of HCM and
MVPTherefore Valsalva and standing increase the murmur of HCM and
MVP Squatting reduces the murmur of HCM and MVPSquatting reduces
the murmur of HCM and MVP Slide 87 35 year old woman with
increasing dyspnea and fatigue, a history of rheumatic heart
disease, a loud S1, a prominent S2 followed by an opening snap, and
a diastolic rumble which becomes louder at the end of diastole
A.Mitral stenosis B.Aortic regurgitation C.VSD D.PDA Slide 88 35
year old woman referred for palpitations and murmur, normal S1 with
wide fixed splitting of S2, and a grade II/VI systolic ejection
murmur at the LUSB A.Pulmonary stenosis B.VSD C.ASD D.Aortic
stenosis Slide 89 65 year old man who is asymptomatic, noted to
have a normal S1, a second heart sound of normal intensity which
splits with expiration and becomes single with inspiration
(paradoxical splitting), and no murmur A.Left bundle branch block
B.Right bundle branch block C.Aortic stenosis D.HTN This was on the
1994 IM board exam! Slide 90 Best of luck! Get a good nights
sleep!Get a good nights sleep! Trust your initial reaction.Trust
your initial reaction. Use clinical judgment.Use clinical judgment.
Look for the point of the question.Look for the point of the
question. If no clue, guess and move on. Can always come back if
time allows.If no clue, guess and move on. Can always come back if
time allows. Slide 91 And remember Slide 92 Bonus questions! E-mail
me with your answers. Or if you have questions or
suggestions.E-mail me with your answers. Or if you have questions
or suggestions. [email protected]@[email protected]
Slide 93 25 year old man who presents to the ER following a stab
wound to the left chest, found to have a BP of 80/50, HR 130, a
pulsus paradoxus of 20 mm Hg, distended neck veins, and distant
heart sounds A.Constrictive pericarditis B.Cardiac tamponade
C.Restrictive cardiomyopathy D.Tension pneumothorax Slide 94 28
year old woman with primary pulmonary hypertension, elevated neck
veins with a prominent v wave, a II/VI pansystolic murmur at the
LLSB that increases with inspiration, and a pulsatile liver
A.Mitral regurgitation B.Tricuspid regurgitation C.VSD D.ASD Slide
95 45 year old veteran who presents with palpitations and SOB after
a week-end of binge drinking, on exam has a radial pulse of 120, an
apical pulse of 180, and an irregularly irregular heart rhythm
A.PACs B.Bigeminy C.Atrial flutter D.Atrial fibrillation Slide 96
25 year old woman with a history of recent onset hypertension,
diminished femoral pulses, and a grade II/VI systolic ejection
murmur at the LSB and back A.Subclavian stenosis B.Peripheral
vascular disease C.Coarctation of the aorta D.Renal artery stenosis
Slide 97 70 year old man from a nursing home with elevated neck
veins that increase with inspiration and prominent x and y
descents, normal S1 and S2 with a loud S3 knock, and no murmur
A.Constrictive pericarditis B.Restrictive cardiomyopathy C.Cardiac
tamponade D.Tricuspid regurgitation Slide 98 35 year old woman
referred for murmur, has a continuous murmur at the 2 nd left
intercostal space A.Tetralogy of Fallot B.Pulmonary stenosis
C.Patent ductus arteriosus D.Coarctation of the aorta Slide 99 35
year old woman with a history of a murmur since birth, has a grade
IV/VI pansystolic murmur at the left sternal border A.Tetralogy of
Fallot B.ASD C.VSD D.Transposition of the great arteries Slide 100
5 year old boy with a history of cyanosis and digital clubbing,
noted to stop and squat during play, has an RV lift, a single S2,
and a grade III/VI systolic ejection murmur at the LUSB A.Tetralogy
of Fallot B.VSD C.Pulmonic stenosis D.ASD E.Transposition of the
great arteries Slide 101 You are performing routine physical exams
for your local high school athletes. You notice a continuous murmur
over the neck in a healthy- appearing 18 y/o girl while she is
sitting on the stretcher. What is the most likely diagnosis and how
do you confirm it? Venous hum! Lay her back down and it will go
away. Slide 102 The next patient has a 2/6 midsystolic murmur at
the LUSB with physiologic splitting of S2. What is the most likely
diagnosis? Innocent murmur - always < 2/6 murmur - never
diastolic - never pansystolic - normal S2 Slide 103 A 30 y/o man
presents with chest pain which is less severe when he sits up and
leans forward. On exam, he has a scratchy sound in systole and
diastole heard throughout his precordium. This is his EKG. Most
likely diagnosis is - A.Myocardial infarction B.Pulmonary embolus
C.Pericarditis D.Pneumothorax Slide 104 Bonus questions - answers
B, B, D, C, A, C, C, AB, B, D, C, A, C, C, A Venous hum, innocent
murmurVenous hum, innocent murmur C Remember, e-mail me for
questions!Remember, e-mail me for questions!
