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Internal Medicine Board Review Cardiology Mike McMullan, M.D., FACC July 17, 2014.

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1 Internal Medicine Board Review Cardiology Mike McMullan, M.D., FACC July 17, 2014

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

3 Cardiology Topic Breakdown

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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!

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

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 Means–Lerman scratch

8 The Basics

9 Where does S1 occur? A.a B.b C.c D.d E.e F.f S1

10 Where does S2 occur? A.a B.b C.c D.d E.e F.f S2

11 Where does S4 occur? A.a B.b C.c D.d E.e F.f S4

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

13 Which of these sounds is lost in a patient with atrial fibrillation? A.S1 B.S2 C.S3 D.S4

14 The Basics 3 additional heart sounds3 additional heart sounds –Click (occur with valve closure)  Usually MVP  Rarely tricuspid click in Ebstein’s 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

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

16 Basic Murmurs S1 S2 S1 S2 S4 S3 OS ES

17 Venous Waveforms in a Nutshell

18 Ventricular systole Ventricular systole

19 Large “v” Waves

20 What’s the diagnosis? A.Aortic stenosis B.Aortic regurgitation C.Mitral regurgitation D.Tricuspid regurgitation

21 What’s the diagnosis? A.Aortic stenosis B.Aortic regurgitation C.Mitral regurgitation D.Tricuspid regurgitation

22 What’s the diagnosis? A.Mitral regurgitation B.Mitral stenosis C.Aortic regurgitation D.Aortic stenosis x LV y LA mmHg

23 What’s the diagnosis? A.Aortic stenosis B.HCM with obstruction C.MVP D.Aortic regurgitation Pulsus bisferiens Brockenbrough sign

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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

26 Breaking It Down Pericardial disease (1-4 questions)Pericardial disease (1-4 questions) –Cardiac tamponade –Constrictive pericarditis –Acute pericarditis

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 – Beck’s triad (hypotension and elevated neck veins with quiet precordium), pulsus paradoxus, electrical alternansDiagnosis – Beck’s 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

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29 RA Pressure in Tamponade

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31 Constrictive Pericarditis Scenarios – post-radiation for lymphoma, CTD, TBScenarios – post-radiation for lymphoma, CTD, TB Diagnosis – dyspnea, elevated JVP, Kussmaul’s sign, edema, pericardial knockDiagnosis – dyspnea, elevated JVP, Kussmaul’s 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

32 Constrictive Pericarditis Constrictive Pericarditis Kussmaul’s sign

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34 125 0 LA Equalization of Diastolic Pressures RA RV LV Constrictive Pericarditis X Y Y>X Square-root sign RVEDP > 1/3 RVSP

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 mg TID or –ASA 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

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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 BP’s –If cyanotic pt (unlikely), probably Tetralogy of Fallot –Pregnancy – tolerated in all patients except pulmonary HTN and cardiomyopathies

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

40 Atrial Septal Defect

41 ASD EKG

42 ASD TEE

43 ASD Occluder

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

45 Ventricular Septal Defect

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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

49 Patent Ductus Arteriosus

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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 Turner’s syndromeScenario – young adult with HTN, association with Turner’s 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

52 Coarctation of Aorta

53 Coarctation CXR

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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 Eisenmenger’s (secondary pulm HTN with conversion to right-to-left shunt) most commonly occurs with VSDEisenmenger’s (secondary pulm HTN with conversion to right-to-left shunt) most commonly occurs with VSD Ebstein’s may present as cyanosis in adult, usually with palpitations due to right-sided accessory pathway, marked RAE on EKG and echoEbstein’s may present as cyanosis in adult, usually with palpitations due to right-sided accessory pathway, marked RAE on EKG and echo

56 Tetralogy of Fallot

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 Marfan’s and coarctation are at higher risk for aortic rupture during surgeryMarfan’s and coarctation are at higher risk for aortic rupture during surgery

58 Pregnancy and Heart Disease High riskHigh risk –Eisenmenger’s syndrome –Severe pulmonary HTN –Severe aortic stenosis/LVOT obstruction –Coarctation of the aorta with obstruction –Marfan’s 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

59 Risk of CHD in Offspring of Parents with CHD Typically 3-12%Typically 3-12% Can be up to 50% (Marfan’s syndrome)Can be up to 50% (Marfan’s syndrome) Fetal ultrasonography weeksFetal ultrasonography weeks

60 Breaking It Down Valvular heart disease (2-5 questions)Valvular heart disease (2-5 questions) –Aortic stenosis – elderly vs younger –Aortic regurgitation – Marfan’s 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

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

62 Aortic Regurgitation Scenario – Marfan’s syndrome, endocarditisScenario – Marfan’s 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

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

64 MVP

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

66 HCM

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68 HCM EKG

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

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)

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

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

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

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

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, Osler’s nodes, Roth’s spots, anemia, leukocytosis, elevated ESR and CRP, glomerulonephritisDiagnosis – clinical picture, fever, regurgitant murmur, splenomegaly, Janeway lesions, Osler’s nodes, Roth’s 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

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80 The Bottom Line Recognize word associationsRecognize word associations –Irregularly irregular –Mid-systolic click –Pulsus paradoxus –Pulsus alternans –Electrical alternans –Pulsus parvus et tardus –Kussmaul’s sign –Large v waves –Prominent x and y descents –Fixed splitting of S2 –Paradoxical splitting of S2 –Wide physiologic splitting of S2

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

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

83 40 year old man with Marfan’s 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

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

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

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

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

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

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!

90 Best of luck! Get a good night’s sleep!Get a good night’s 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.

91 And remember…

92 Bonus questions! me with your answers. Or if you have questions or suggestions. me with your answers. Or if you have questions or suggestions.

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

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

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.PAC’s B.Bigeminy C.Atrial flutter D.Atrial fibrillation

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

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

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

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

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

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.

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

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

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, me for questions!Remember, me for questions!


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