carduac 1

A 68-year-old patient sees his primary care doctor for complaints of increasing shortness of breath, especially with exertion. He also has experienced some chest pain with these episodes, but it subsides when he is at rest. Upon examining the patient, the doctor notices that the patient's head seems to be bobbing up and down. On exam, he has a widened pulse pressure. What will the doctor most likely hear upon auscultating this patient's heart?

This patient has signs and symptoms of aortic regurgitation (AR). AR causes a back flow of blood into the left ventricle and pulmonary system. When left-sided and pulmonary pressures increase, patients can experience dyspnea, especially on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Angina (chest pain) can develop when there is a decrease in coronary flow, which causes ischemia. This decrease in coronary flow occurs because coronary filling occurs in diastole. However, with AR the blood flows back into the left ventricle and is unable to flow into the coronary circulation. On physical exam, these patients have widened pulse pressures because the systolic pressure is increased to maintain cardiac output and the diastolic pressure is decreased with the back flow of blood from aorta to left ventricle. Bounding pulses can be felt, and head bobbing can be seen due to chronic widened pulse pressures. The murmur heard is a diastolic "blowing" murmur of blood moving from aorta to left ventricle across the aortic valve during relaxation.

The parents of a 15-month-old boy come to the office with their son because they are concerned that he is too skinny. He is at the 98% for height but only the 25% for weight for his age. His arms and legs are extremely long and slender and he has tapering fingers on both hands. On auscultation, the physician hears a crescendo murmur following a midsystolic click.

This patient has Marfan's syndrome, which is due to mutation in the fibrillin-1 gene and is inherited in an autosomal dominant fashion. Patients with Marfan's syndrome are tall with long, thin extremities and hyperextensive joints. Pectus excavatum, a convexity of the chest at the sternum may be noted. Cardiac abnormalities are common. Patients can have mitral prolapse due to a floppy mitral valve, as seen in this patient, and/or aortic insufficiency due to aortic root dilation.

A 20-year-old male presents to the office for a sports physical. He has no health problems except for prior surgery for lens subluxation. He is 76 inches tall with long, thin extremities and digits. His chest has an unusual inward slope, and he has very flexible joints. Upon cardiac auscultation, an early, soft, diastolic decrescendo murmur is heard at the apical area.

This patient has Marfan's syndrome. This is a connective tissue disease caused by a mutation in fibrillin gene. These patients are often tall with long extremities, arachnodactyly, pectus excavatum, and hyperextensible joints, all of which this patient has. One of the major complications in these patients is aortic dissection. This is because Marfan's causes a cystic medial necrosis of the aorta which leads to aortic insufficiency and vulnerability to dissection. The diastolic murmur heard indicates this patient has aortic insufficiency and needs to have further work-up. An S3 gallop or a mid-diastolic murmur (Austin-Flint murmur, in severe disease) can also sometimes be heard. Subluxation of the lens and berry aneurysms can also occur. This genetic condition has autosomal dominant inheritance and is often diagnosed in adolescence.

A 40-year-old man with a history of schizophrenia is who has been well controlled on haloperidol for the last 10 years is found unresponsive on his couch by his wife. His neck is twisted and rigid, and he is immediately taken to the emergency room by ambulance. Upon admission to the emergency room, his temperature is 37°C (98.6°F), pulse is 110 beats/minute, blood pressure is 100/60 mm Hg, and his oxygen saturation is 80% on 100% O2 non-rebreather mask. He is immediately intubated. His ECG is shown below.

This patient has an ECG representative of Torsades de Pointes, which is an irregular rhythm that "twists" around the ECG axis. It is probably a result of this patient's chronic antipsychotic medication which is known to prolong the QT interval. Although cardioversion should be attempted because he is unstable, an infusion of magnesium should also be started. Magnesium can be started as bolus and then transitioned to a continuous infusion regardless of the initial magnesium level. Magnesium helps decrease the influx of calcium within the cardiac cells, decreasing the early depolarization contributing to the abnormal electrophysiology.

A female neonate is born at 36 weeks gestation, weighing 7.2 pounds with APGAR scores of 8 and 9 at one and five minutes of life, respectively. Vitals are within normal limits for a newborn. The baby is nude, warm, and settled. The baby's physical exam is within normal limits with the exception of a 4/6 heart murmur. Echocardiography demonstrates ventricular septal defect, and an overriding aorta that receives blood from both ventricles. Which of the following cardiovascular changes are also present?

This patient has tetralogy of Fallot. This is the most common cyanotic congenital heart disease in older children and adults, but it can be detected in infancy due to presence of a heart murmur. It is associated with trisomy 21. The four lesions found are: ventricular septal defect, an overriding aorta that receives blood from both ventricles, right ventricular hypertrophy, and pulmonic stenosis. The right ventricular hypertrophy results from pulmonic stenosis due to right ventricular outflow obstruction.

A 36-year-old female presents to the emergency department with a complaint of her heart beating out of her chest. She is unable to give any detailed medical history but complains that her chest started feeling funny about one hour ago and she feels like she is going to die. An electrocardiogram and select laboratory analyses are below: Sodium 142 mEq/L Potassium 3.8 mEq/L Calcium 9.1 mg/dL Glucose 112 mg/dL Creatinine kinase 63 ng/mL (38-120 ng/ml) Creatinine kinase- ML 1.2 ng/mL (0-3 ng/ml) Troponin 0.02 ng/mL (<0.4 ng/ml)

This patient is experiencing Torsades de pointes (literally "turning of the points"), a type of ventricular tachycardia. The cause of this condition is often due to prolongation of the QT interval. The QT interval corresponds to the contraction of the ventricles after they have been depolarized (QRS complex) and before they repolarize (T wave). Normally the QT interval is less than 400 ms, but it can be prolonged due to congenital or acquired reasons. The most common acquired prolongation is due to drugs. This patient is experiencing Torsades de pointes (literally "turning of the points"), a type of ventricular tachycardia. The cause of this condition is often due to prolongation of the QT interval. The QT interval corresponds to the contraction of the ventricles after they have been depolarized (QRS complex) and before they repolarize (T wave). Normally the QT interval is less than 400 ms, but it can be prolonged due to congenital or acquired reasons. The most common acquired prolongation is due to drugs. Antipsychotics, antibiotics, and antiviral drugs are among those with the highest risk for QT prolongation. Given the lack of medical history, the antipsychotic ziprasidone is the drug most likely to have prolonged this patients QT, resulting in Torsades. She likely has an underlying psychiatric disorder. A baseline electrocardiogram should be obtained on patients who are started on high risk drugs.

A 45-year-old man goes to the emergency department because of severe shortness of breath. He has not seen a doctor in over ten years because he is uninsured. He says that he has noticed shortness of breath on exertion for the past two years that has become progressively worse. Now he has shortness of breath and wheezing at rest. On physical examination, he has jugular venous distension, a point of maximal impulse felt 4 cm to the left of the midclavicular line, and a holosystolic murmur best heard at the apex with radiation to the axilla. Bibasilar crackles on lung examination and the liver edge is palpated below the edge of the ribs. Chest x-ray reveals an enlarged heart as well as increased pulmonary markings. Echocardiogram reveals a dilated heart with a left ventricular ejection fraction of 30%. Which of the following can cause his condition?

This patient is presenting with congestive heart failure secondary to dilated cardiomyopathy. In dilated cardiomyopathy, the left ventricle progressively dilates, leading to poor cardiac output as well as mitral regurgitation. The murmur of mitral regurgitation is a holosystolic murmur that is best heard at the apex with radiation to the axilla. Over time the patient is no longer able to compensate for the dilation and signs of congestive heart failure - elevated JVP, hepatomegaly, pulmonary edema - are found. The heart is enlarged in both chest x-ray and echocardiogram. Causes include alcohol abuse, beriberi, cocaine abuse, coxsackie virus, Chagas disease, and doxorubicin.

A 72-year-old man comes to the emergency department complaining of episodes of palpitations, shortness of breath, and lightheadedness over the past several weeks. He denies chest pain and notes that episodes can come on at any time, with or without exertion. Review of systems reveals increasing fatigue over the same time period. An electrocardiogram is shown below.

This patient is presenting with the classic electrocardiographic findings of second degree heart block type 2 (also known as Mobitz II). This dysrhythmia is characterized by dropped QRS complexes after normal P waves with normal PR interval. In this rhythm strip, there is a dropped QRS complex every 2 P waves. Due to frequent progression of this dysrhythmia to third degree, or complete, heart block, evaluation for and placement of a pacemaker is the treatment.

A 77-year-old woman presents to her primary care physician for a routine physical examination. She describes occasional palpitations, "like my heart is racing," that occur once per week and have been occurring "for the past few years." She otherwise feels well and has no complaints. Her temperature is 37.5°C (99.5°F), blood pressure is 121/81 mm Hg, heart rate is 92 beats/minute, and respiratory rate is 17 breaths/minute. Her past medical history includes diabetes mellitus type II and hypertension. Her medications include metformin, hydrochlorothiazide, and lisinopril. The cardiac examination reveals an irregularly irregular heart rhythm. The remainder of the examination is unremarkable. An electrocardiogram (ECG) shows an irregularly irregular heart rhythm, an absence of P waves, and an irregular baseline. An ECG performed 13 months ago is identical. Which of the following is most appropriate treatment?

An irregularly irregular rhythm is characteristic of atrial fibrillation, as are the ECG findings described above. The treatment of atrial fibrillation depends on its duration, symptomatology, and etiology. Acute-onset atrial fibrillation is usually an indication for cardioversion and a search for its cause (e.g., myocardial infarction). Atrial fibrillation that has persisted for more than 12 months is considered permanent. Permanent atrial fibrillation is dangerous because clots can form in the stagnant blood in the atria, then enter the systemic circulation. Ischemic stroke is a dreaded complication of untreated atrial fibrillation. On Step 1, most patients with permanent atrial fibrillation require warfarin therapy.

A 65-year-old Hispanic man presents to his primary care physician for a 6-month follow-up after a myocardial infarction. He feels well and has no complaints. His past medical history, in addition to the myocardial infarction, includes hypertension and osteoarthritis. His temperature is 37.1°C (98.8°F), blood pressure is 131/81 mm Hg, heart rate is 52 beats/minute, and respiratory rate is 16 breaths/minute. His medications include hydrochlorothiazide, metoprolol, aspirin, lisinopril, atorvastatin, and acetaminophen as needed. Which of the following is the proper work-up and/or treatment for this patient's bradycardia?

Asymptomatic bradycardia rarely requires treatment. The focus should be on discovering the cause of the abnormal rhythm rather than immediate intervention. This patient is taking a beta-blocker (metoprolol), which is likely responsible for his bradycardia. Sinus bradycardia should be confirmed with electrocardiography. However, with an absence of symptoms and an obvious etiology, no intervention is required.

A 46-year-old woman comes to her family physician complaining that she has noticed increasing difficulty with her daily power walks. She indicates that she used to be able to walk three miles every morning but recently she has been feeling palpitations and shortness of breath and has had to decrease the distance she walks. Her past medical history is significant only for hypothyroidism treated with levothyroxine. Review of systems is negative for fever, weight loss or gain, cough, and edema. Her temperature is 37.2°C (98.9°F), pulse is 125 beats/min, respirations are 18 breaths/min, and blood pressure is 115/75 mm Hg. An electrocardiogram and laboratory analyses are obtained. Sodium 136 mEq/L Potassium 4.8 mEq/L Calcium 9.8 mg/dL Glucose 97 mg/dL Creatinine kinase 89 ng/mL (38-120 ng/ml) Creatinine kinase-MB 1.2 ng/mL (0-3 ng/ml) Troponin 0.02 ng/mL (< 0.4 ng/ml) Thyroid stimulating hormone 4.2 mcU/mL

Based on the electrocardiogram, this woman most likely has Wolff-Parkinson-White (WPW) syndrome, which is caused by an accessory conduction pathway. An accessory pathway electrically connects the atria to the ventricles, bypassing the AV node, which normally slows the electrical impulse. As a result, the PR interval, which represents the impulse slowing at the AV node, is shortened. Thus, dangerous tachyarrhythmias can occur in patients with WPW who develop atrial fibrillation or flutter. Characteristic delta waves, or slowing of the upstroke of the QRS complex, are often seen also. While the syndrome often presents in the pediatric population due to the congenital nature of the accessory pathway, it can also present in older patients. Treatment entails rate and rhythm control, and if not effective, radiofrequency ablation of the accessory pathway.

In practice, clinicians use a patient's

CHADS2 score to determine therapy. A patient gets 1 point for each of the following risk factors: Congestive heart failure, Hypertension, Age over 75, and Diabetes mellitus. A patient gets 2 points for a previous Stroke (either cerebrovascular accident or transient ischemic attack). A score of 0−1 is an indication to start aspirin therapy, while a score of 2+ is an indication to start warfarin therapy (with an internationalized normalized ratio target of 2−3). This patient is over 75 and has hypertension and diabetes; thus, her CHADS2 score is 3, and warfarin therapy is indicated

A 2-year-old Asian male presents with a fever lasting 6 days that has not responded to acetaminophen. Upon exam, there is a diffuse, erythematous maculopapular rash, bilateral non-purulent conjunctival injection, and dry, red lips. The oropharynx is markedly erythematous. He has lymphadenopathy of the right the anterior cervical chain and sausage-like swelling of the hands and feet. He has negative Weil-Felix and VDRL tests. An echocardiogram reveals mild dilation of the proximal left anterior descending coronary artery and left circumflex artery. The child is given an intravenous medication, promptly recovers the following days. He is discharged with instructions to take an oral medication to take for the next 2 months. If the patient develops an influenza or varicella infection after hospitalization, what complication is most likely to occur?

This patient has classic Kawasaki disease, which typically presents in children under 5 years of age with high fevers that are unresponsive to antipyretics for greater than 5 days. In addition to a fever greater than 5 days, the disease is diagnosed by at least 4 of the following: 1. Extremity Changes: erythema of palms/soles or desquamation of hands/feet. Desquamation typically occurs two weeks after the fever begins. 2. Polymorphous rash 3. Bilateral bulbar conjunctival injection without purulence or exudates 4. Changes in the lips and oral cavity, which may include strawberry tongue, cracked lips, and injected mucosae. 5. Cervical lymphadenopathy, usually unilateral Other positive lab findings may include a high erythrocyte sedimentation rate, a high C-reactive protein, sterile pyuria, and leukocytosis.

A 32-year-old woman presents to her family physician's office for an annual physical exam. She feels well and has no complaints. Cardiac examination reveals a click-like sound in early systole that is followed by a systolic murmur, grade II/III, best heard at the apex and radiates to the axilla. She says that her prior physicians have also noted the murmur. She was told that most people with this type of murmur do not have symptoms. Which of the following would cause the murmur to occur later in systole?

Extra tissue in the mitral valve can result in a "floppy" mitral valve that does not fit properly within the annulus. The result is that, during systole, blood can escape the ventricle and travel retrograde through the valve into the atrium. Maneuvers that increase volume in the left ventricle, such as squatting, cause the annulus to widen, becoming closer in size to the large valve. This causes the prolapse—and thus the click and ensuing murmur—to occur later in systole because the valve "fits" better in the space between the chambers. Conversely, maneuvers that decrease the size of the left ventricle, such as standing after squatting or amyl nitrate inhalation, allow more area of valve overlap, more regurgitant flow, and thus the click-murmur occurs earlier in systole.

A 65-year-old woman presents with shortness of breath and hemoptysis. Upon physical exam, oral ulcers are seen and bloody nasal discharge is noted. A computed tomography of the thorax reveals diffuse ground glass opacities in both lungs. A urine dipstick reveals the presence of blood and protein in the urine. Initial labs sent reveal a serum creatinine of 5.5 mg/dL and a BUN of 76 mg/dL. Subsequent labs reveal that cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) and anti-proteinase 3 (anti-PR3) antibody tests are positive. What is the most likely diagnosis?

Given the positive cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) test as well as signs of bloody nasal discharge, alveolar hemorrhage and glomerulonephritis, Wegener's is the most likely diagnosis. Wegener's granulomatosis is a vasculitis predominantly involving the kidneys as well as the upper and lower respiratory tracts. Renal symptoms include a high BUN, high Creatinine, hematuria, and proteinuria, which can point to a rapidly progressive glomerular nephritis. It is important to note that Wegener's granulomatosis includes both upper respiratory tract symptoms (sinusitis, purulent/bloody nasal discharge, oral ulcers) as well as lower respiratory tract symptoms (cough, hemoptysis, diffuse alveolar hemorrhage), which differentiates it from Goodpasture's syndrome, another pulmonary-renal vasculitis. On a computed tomography of the chest, the finding of ground glass opacities is indicative of diffuse alveolar hemorrhage. Another key point in diagnosing Wegener's granulomatosis is a positive c-ANCA test, which highly sensitive and specific for patients with Wegener's. This is very commonly tested because it is one of the most common vasculitides in the United States.

A 17-year-old male was playing in his high school basketball game when he suddenly became short of breath and immediately fell unconscious. A family history of similar episodes occurring in a number of other family members was discovered, and a few relatives had passed away at a young age. The patient had been previously healthy to his knowledge. What was the cause of this patient's event?

This patient has hypertrophic cardiomyopathy and was very lucky to have survived as many patients first presentation is sudden cardiac death, often in young athletes. This patient's presentation, as well as family history, are keys to the diagnosis. Hypertrophic cardiomyopathy is often an autosomal dominant disease, and patients can have a family history of sudden cardiac death. The myocardium becomes concentrically hypertrophied with sarcomeres in parallel which causes a thickened and stiff ventricle. These ventricles can no longer fill properly, leading to a diastolic heart failure. A lack of cardiac output results in syncopal episodes. Outflow obstruction also occurs as the myocardial septum thickens and blocks flow of blood through the mitral valve. This causes an increase in pulmonary venous pressure, which can lead to pulmonary congestion and shortness of breath. This pathophysiology mimics the left ventricular hypertrophy, which similarly causes diastolic dysfunction that occurs in patients with long-standing history of hypertension.

A 17-year-old boy is rushed to the hospital by ambulance after having an episode of syncope during soccer practice. He is awake and alert upon presentation with a heart rate of 70/min and blood pressure of 110/80 mm Hg. He has no prior medical history and takes no medications. He notes that he has been feeling short of breath and dizzy following long soccer practices and games over the last month but has not told anyone since he did not want to lose his starting position. An echocardiogram is remarkable for severe left ventricular hypertrophy, a thickened right ventricle, and a prominent interventricular septum. Which of the following is most likely to be associated with his condition?

Hypertrophic cardiomyopathy is a disease of the myocardium in which a portion of the myocardium is hypertrophied without any obvious cause. It is perhaps the most well-known leading cause of sudden cardiac death in young athletes. It is hereditary in >70% of cases, caused by mutations in beta-myosin heavy chain. Patients typically present with no prior symptoms and either die unexpectedly usually during exertion or present with symptoms of syncope, chest pain, palpitations, and/or dyspnea during physical activity.

An 81-year-old man comes to the hospital with shortness of breath that has progressively worsened over the last six days. His past medical history is significant for a prior anterior wall myocardial infarction five years ago. He takes metoprolol, aspirin, and lisinopril daily. Chest x-ray reveals bilateral pulmonary infiltrates. B-type natriuretic peptide is elevated over 1100 pg/mL. EKG shows an old anterior wall infarct with no changes as compared to his prior EKG two months ago. He is admitted to the hospital and is aggressively diureses with intravenous furosemide. His shortness of breath improves, but on the fifth day of hospitalization, his potassium level is 2.5 mEq/L.

Hypokalemia is a common side effect from aggressive use of furosemide for treatment of pulmonary edema. EKG changes include flattened T waves and the presence of U waves. Patients may also have muscle weakness, rhabdomyolysis, and gastric ileus.

A 17-year-old male presents to the pediatrician for a yearly sports physical. He has been well in the past year and has no specific complaints today. He denies exercise intolerance, shortness of breath, chest pain, or palpitations. His father has hypertension, and his mother is in remission from invasive ductal breast cancer. His uncle died suddenly while playing college football at age 22. He denies alcohol and tobacco use. On exam is he is afebrile, and vitals are within normal limits. He is athletic appearing at 5'10" tall and weighing 81.8 kg (180 lbs). Lungs are clear. There is a grade III/IV harsh systolic murmur heard best at the left sternal border. Point of maximal impulse is slightly displaced on the lateral chest wall. Which of the following maneuvers will most likely intensify this patient's murmur?

This patient has hypertrophic cardiomyopathy, an autosomal dominant mutation in the genes encoding the contractile apparatus of cardiac muscle. Asymmetric hypertrophy of the interventricular septum leads left ventricular outflow obstruction and the associated murmur: a systolic ejection, crescendo-decrescendo murmur heard best at the left sternal border. Conditions, position, and maneuvers that reduce left ventricular end diastolic volume (decreased preload, decreased afterload) will worsen the outflow obstruction and intensify the associated murmur. These include Valsalva maneuver (decrease preload), moving from squatting to standing, nitrate medications (decreased preload), vasodilators (decreased afterload), and diuretics.

A 30-year-old woman presents at the pediatrician's office with her four-year-old son because he is becoming increasingly short of breath after running short distances. She also notes that his lips often appear blue. The mother did not have routine prenatal care during her pregnancy and mentions that she only took folic acid, extra vitamin B12, Lithium for her bipolar disorder, and labetalol for a long history of hypertension. Upon physical exam the child displays cyanosis and clubbing of his fingers. Auscultation reveals a holosystolic murmur heard best at the lower left parasternal area and at the apex that increases in intensity during inspiration as well as a widely split S1. What is the most likely cause of this child's presentation?

Lithium use during the first trimester is associated with Ebstein's anomaly, an embryological cardiac defect due to abnormal development of the tricuspid valve. The valve becomes apically displaced and distorted, leading to atrialization of the right ventricle. Backwards flow of blood and tricuspid regurgitation occur as a result. Auscultation will reveal a blowing holosystolic murmur heard best at the lower left sternal border, increased with inspiration.

A 65-year-old white man presents to his primary care physician to establish care as a new patient. His temperature is 37.5°C (99.5°C), heart rate is 76 beats/minute, respiratory rate 17 breaths/minute, and blood pressure of 151 mmHg/97 mmHg. He has no particular complaints, except that his blood pressure has been around 150/100 for at least 20 years, and he thought it might be time to get it "checked out." Physical exam reveals an S4 heart sound and a point of maximum impulse that is displaced to the mid-axillary line. The examination is otherwise normal. Which of the following is likely present in this patient?

Longstanding hypertension results in increased afterload against which the left ventricle must work, resulting in additional sarcomeres being added parallel to the long axis of the cells. The muscle thickens, resulting in "concentric hypertrophy." The physical exam finding of a displaced point of maximum impulse (PMI) points toward left ventricular hypertrophy (LVH), and the S4 heart sound can indicate an atrium pushing blood into a thickened ventricle--as is the case in concentric LVH.

A 31-year-old woman comes to the office for a regular physical examination. A murmur is noted upon auscultation of the heart. The patient is instructed to perform a Valsalva maneuver, which prolongs the duration of the murmur. The murmur is most likely due to which of the following heart lesions?

Mitral valve prolapse is due to excess or redundant mitral leaflet tissue secondary to myxomatous degeneration of valve tissue- this tissue will prolapse towards the left atrium in systole and result in the characteristic mid to late-systolic click and mid-late systolic rumble. Standing or the Valsalva maneuver will reduce left ventricular chamber size, which brings the mid-systolic click closer to the first heart sound and prolongs the duration of the murmur. On the other hand, squatting will increase left ventricular chamber size, delay the onset of the click, and, therefore, decrease its duration.

2) Uveitis

Patients typically present with acute onset of unilateral eye pain, redness, photophobia, increased lacrimation, and blurred vision.

3) Aortic regurgitation

Patients with long-standing ankylosing spondylitis can develop cardiovascular complications such as aortic valvular insufficiency

A 65-year-old man presents to the emergency department with diaphoresis and chest pain. The pain began one hour ago during a walk. It is 7/10 in intensity, constant, and radiates to his jaw. His medial history includes type 2 diabetes mellitus controlled with oral hypoglycemics, hypertension controlled with enalapril and hydrochlorothiazide, and hyperlipidemia. He currently smokes one pack of cigarettes per day for the last 40 years and drinks half a bottle of wine a day. On examination, his temperature is 37°C (99.5°F), pulse 55/min, respirations are 18/min, and blood pressure is 115/70 mm Hg. He appears uncomfortable and is holding his left chest. His ECG shows ST-segment elevations in leads II, III, and AVF, with ST-depressions in V1 and V2. Which of the following is the most likely cause for his condition?

ST-elevations in the inferior leads indicate inferior wall myocardial infarction (MI). The V1 and V2 depressions are reciprocal changes that occur on the ECG since there is infarction in opposite region of the heart. An inferior MI is caused by occlusion of either the left circumflex artery or the right coronary artery. This patient, however, is hypotensive and bradycardic, which distinguishes a right-sided MI from a left-sided MI. In the majority of individuals the right circumflex artery (RCA) supplies the sinoatrial (SA) node and the right ventricle. Infarct of the RCA is more common in an inferior MI; therefore, this patient is pre-load dependent due to right coronary artery occlusion impairing function of the right ventricle.

An 80-year-old African-American woman presents to her primary care physician three weeks after the death of her husband of 53 years. Vital signs are within normal limits. She is tearful and distraught on examination, and her physician prescribes fluoxetine and lorazepam. Two weeks later, the patient presents to the emergency room with acute-onset substernal pain that she rates 8/10 in severity. Her temperature in the ER is 37.4°C (99.4°F), blood pressure is 95/62, heart rate is 124 beats/minute, and respiratory rate is 29 breaths/minute. Laboratory results reveal mildly elevated troponins and a urine toxicology screen positive for benzodiazepines only. An electrocardiogram shows ST elevations in leads V1, V2, V3, and V4. Ten minutes after arrival, the patient develops profound hypotension and admitted to the intensive care unit for aggressive management. Which of the following is most likely responsible for this patient's signs and symptoms?

Takotsubo cardiomyopathy, also called stress-induced cardiomyopathy or broken-heart syndrome, presents similarly to acute coronary syndrome (which includes unstable angina and myocardial infarction). It is caused by extreme psychosocial or physical stress—such as the death of a close relative. It is much more common in women than men. ST elevation in the precordial leads (V1−V4) is a common finding, and the ST elevation and the clinical presentation are usually more dramatic than the troponin elevation. Echocardiography classically shows ballooning of the heart's apex and can also show midventricular hypokinesis. The term "Takotsubo" refers to a Japanese octopus trap with an appearance similar to the apical ballooning often seen in this syndrome. Takotsubo cardiomyopathy can lead to cardiogenic shock, as in this patient. Treatment is based on the patient's clinical picture and can include diuretics, inotropes, and beta-blockers; the specifics of treatment are likely beyond the scope of USMLE Step 1

A newborn boy is born to a 23-year-old mother at 34 weeks gestation. The mother has a history of type I diabetes mellitus and had difficulties maintaining good glucose control throughout the pregnancy. On the child's third day of life he becomes cyanotic. X-ray reveals an abnormal "boot shaped" appearance of the heart. Which of the following most determines the severity of his condition?

Tetralogy of Fallot is a congenital heart defect that is classically understood to involve four anatomical abnormalities, even though only three of these are always present. These defects are right ventricular hypertrophy, pulmonary stenosis, ventricular septal defect (VSD), and overriding aorta. Of these, the degree of pulmonary stenosis determines the severity of the defect. This is due to the fact that the severity of the obstruction to right ventricular outflow determines the direction of flow. If pulmonic stenosis is mild, the abnormality resembles a VSD, and there is no cyanosis. On the other hand, if pulmonary stenosis is significant enough so that outflow is obstructed, right ventricular pressure may exceed systemic vascular resistance, and blood may be shunted right to left, resulting in cyanotic heart disease. Infants with tetralogy of Fallot can have "Tet spells" when they are crying and will squat down to increase systemic vascular resistance.

A 50-year-old man presents to the emergency department with severe substernal chest pain that has not subsided despite taking nitroglycerin. EKG shows ST-elevations in leads V3-V6. The man promptly treated and is admitted for observation. One week after the initial chest pain, the patient again reports having chest pain and the resident physician is attempting to figure out if this is a complication of the initial attack or a repeat of the initial attack. Which lab result below would most strongly suggest that the patient is experiencing a repeat of the initial attack?

The CK-MB is the most reliable test for detecting a repeat myocardial infarction. It is weakly positive from 0 to 6 hours after the beginning of MI, and becomes strongly positive from 12 to 16 hours, peaks at 24 hours and usually disappear by days 3. Troponin I starts to become elevated around 4 hours, peaks around 24 hours and persists even after a week. Even though it is the most specific marker for MI, it is not a good marker to detect a repeat of MI because it can persist for days. LDH peaks around day 3 and usually persists. At 6-day post MI, the patient is at risk for developing cardiac tamponade from myocardial rupture, which can also cause severe chest pain. A positive CK-MB would be the most valuable test in differentiating a repeat myocardial infarction from a cardiac tamponade. Aspartate aminotransferase and myoglobin are not part of the answer choices, but their levels are sometimes taken after an MI, even though neither are specific markers for MI. Aspartate aminotransferase generally peaks around day 2 and then falls. Myoglobin generally rises and falls within 6 hours post MI.

A 50-year-old man with chronic obstructive lung disease and a history of alcohol abuse presents to the doctor's office with worsening shortness of breath over the last week. He says that this is worse on exertion, and he frequently stops for breaks while climbing the stairs. A chest x-ray is abnormal. Biopsy of the lung is shown below.

The image shows the classic "heart failure cells" in the lung which are hemosiderin-laden macrophages. This is most commonly seen in long-standing left-sided heart failure, which increases pulmonary capillary pressure and causes microhemorrhages. These changes can cause induration, leading to increased shortness of breath.

1) Chronic inflammatory disease of spine and sacroiliac joints

The pain associated with ankylosing spondylitis is typically worse in the morning or following periods of inactivity. Patients frequently note morning stiffness lasting around 30 minutes and improvement of their symptoms with physical activity. On imaging, the spine may appear "bamboo-like" due to the formation of bridging syndesmophytes (areas of ossification within the ligaments) that leads to near fusing of the spine (see image below).

A 45-year-old woman is killed in an automobile crash, and an autopsy is performed. Gross pathologic examination of her heart reveals a left ventricular chamber that is markedly increased in size, but the ventricular wall is of normal appearance and width. The right ventricle is grossly normal. Which of the following would most likely have caused the pathologic changes seen in this patient's heart?

The pathologic changes described in the question refer to a form of left ventricular hypertrophy (LVH) called "eccentric hypertrophy." Longstanding disorders that lead to increased preload (i.e., intraventricular volume)--such as aortic regurgitation and mitral regurgitation--cause stress on the ventricular wall. In response, sarcomeres are added "in series," and the muscle's length and width increase, but its thickness remains the same.

A 6 pound, 4 ounce baby girl is born at 36 weeks gestation to a 31-year-old woman. No abnormalities are noted on initial examination. APGAR scores are 8 and 9 at one and five minutes, respectively. An abnormality is noted the next day while listening to the heart and can be heard on the clip in the Exhibit tab. Which of the following is the underlying cause of this child's abnormality?

The patient above has a patent ductus arteriosus. The murmur heard in the clip is characteristic for the diagnosis. It is a continuous, machine-like murmur that is best heard at the second intercostal space. It is from shunting of blood from the pulmonary artery to the aorta. The ductus arteriosus develops during the sixth week of development as a way to shunt blood from the right ventricle to the systemic circulation, bypassing the lungs since reoxygenation occurs at the placenta in the fetus. Normally the duct closes within the first 15 hours following birth but can remain open due to continued prostaglandin E2 production. This occurs more frequently in premature infants, those with respiratory distress syndrome, and infants with other congenital heart defects. Since no other defects are noted, this is likely an isolated case of patent ductus arteriosus.

A 2-year-old child is brought to the pediatrician by his father who reports that his child is easily fatigued after playing, becoming exhausted and breathing heavily. He also "turns blue," according to his father. On exam, a systolic thrill is present anteriorly along the left sternal border and a harsh systolic murmur heard best over left second intercostal space. An x-ray performed in the office is shown below.

The patient described in the vignette above is suffering from a tetralogy of Fallot. A tetralogy of Fallot is caused by a congenital defect in heart development leading to four major anatomical defects: (1) pulmonary artery stenosis, (2) ventricular septal defect, (3) over-riding aorta, and (4) right ventricular hypertrophy. The right ventricular hypertrophy is demonstrated in the radiograph above, which shows a "boot-shaped" heart. In patients with tetralogy of Fallot, the cyanosis and dyspnea is secondary to a bypass of the pulmonary circulation. This occurs as a result of a right ventricular outflow obstruction produced by the stenotic pulmonary artery, as well as the over-riding aorta. As a result, blood does not reach the lungs and is instead shunted to the left ventricle. During "Tet spells," in which these patients become cyanotic and develop bluish-pale skin, they often squat in order to increase pulmonary flow. Squatting is a compensatory mechanism that increases peripheral vascular resistance (PVR) and thus decreases the magnitude of the right-to-left shunt across the ventricular septal defect (VSD).

A 42-year-old man has progressive weakness and difficulty breathing over the past seven weeks. For the past several days, he has also noticed significant ankle swelling, and he decided to consult a physician. He has a past medical history significant for diabetes mellitus and tuberculosis, which was diagnosed three months ago. Physical examination reveals a blood pressure of 110/90, pulse 79, respiratory rate of 14/min. He denies any nausea, vomiting or diarrhea. Troponin, glucose, creatinine, and cholesterol levels are normal. After CT scan, he is diagnosed with constrictive pericarditis. Which of the following is the physiological cause of the man's symptoms?

The patient has constrictive pericarditis, likely secondary to tuberculosis infection. Pericarditis in general has symptoms such as progressive exertional dyspnea and edema. The patient's symptoms lend to the specific diagnosis of constrictive pericarditis as he has a recent history of tuberculosis. A CT scan demonstrating increased early diastolic filling with reduced filling in mid-diastole would confirm the diagnosis, as restrictive cardiomyopathy would instead demonstrate increased left ventricular thickness with infiltration of the myocardium. Thickened myocardium prevents ventricular dilation during diastole.

A 63-year-old female presents to her primary care physician with newly acquired chest pains. She had a myocardial infarction one week ago. On examination, she has a temperature of 101°F, a pericardial friction rub, and new symptoms of heart failure. Which of the following best describes the patient's pericardial rub?

The patient is presenting to the physician with a pericardial rub shortly after a myocardial infarction. The most common type of pericarditis to result after a myocardial infarction (MI) is fibrinous pericarditis, a loud pericardial friction rub that may present with chest pain, fever, and new symptoms of heart failure. The fever is typically low-grade and intermittent.

A 58-year-old man presents to his primary care physician for evaluation of worsening shortness of breath and fatigue. The patient describes feeling more comfortable in the sitting position. Examination of the neck shows elevated jugular venous pressure during inspiration. The cardiovascular exam was largely unremarkable with normal S1 and S2 and negative for S3, S4 and murmurs. Respiratory exam shows decreased breath sound bilaterally. Abdominal exam shows distended abdomen and examination of the extremities shows pitting edema at both ankles. Further testing reveals that the patient's symptoms are due to abnormality in a protein called transthyretin. What is the most likely etiology of the patient's condition?

The patient is presenting with the clinical manifestations of restrictive cardiomyopathy, the least common type of cardiomyopathy. The most common type is dilated cardiomyopathy. While all of the causes listed above can cause restrictive cardiomyopathy, only amyloidosis is associated with transthyretin, which is a protein responsible for transporting vitamin A and thyroxine. Transthyretin amyloidosis is an autosomal dominant condition, and cardiac amyloidosis is one of its subtypes. Cardiac amyloidosis usually manifests around 5th to 6th decades with progressive left ventricular hypertrophy and restrictive cardiomyopathy. The other two forms of transthyretin amyloidosis are neuropathic and leptomeningeal amyloidosis. The neuropathic form of transthyretin amyloidosis primarily affects the peripheral nervous systems, leading to peripheral neuropathy, sexual impotence, diarrhea, constipation, problems with urination, and a sharp drop in blood pressure upon standing (orthostatic hypotension). The leptomeningeal form of transthyretin amyloidosis primarily affects the central nervous system, and causes stroke hydrocephalus, ataxia, spastic paralysis and seizures.

A 20-year-old woman presents for evaluation of palpitations which started about five years ago and have become progressively worse. She had previously been healthy, although she noted that she did not play any sports in high school and could never exercise for more than 10 minutes. A family history reveals that her mother would often cycle from being happy and exuberant to listless and depressed. Physical examination reveals a slightly pale young woman with normal vital signs. Cardiac exam showed wide splitting of the first heart sound. What is the most likely etiology of the patient's condition?

The patient most likely has Ebstein abnormality caused by being exposed to Lithium while in utero. The description of her mother having periods of exuberance and cycling to depression is consistent with Bipolar Disorder. Depending of the severity of defect, the symptoms can appear sometime between neonatal life to adulthood. The apical tissue of the tricuspid valve fails to resorb and becomes displaced if the fetus is exposed to Lithium in utero. This causes distortion of the tricuspid valve leaflets.

A 20-year-old man presents to the emergency room with joint pain and a large rash on his left arm. The rash appears macular with central clearing. The patient has recently been to Maine for a hiking trip. Physical examination shows a well-built young man with normal vital signs. After the diagnosis is confirmed, the patient is started on doxycycline. If the patient was not treated, what type of ECG abnormality is the most likely to show as the disease progresses?

The patient most likely has Lyme disease caused by Borrelia burgdorferi, which is transmitted by Ixodes tick. The disease has 3 stages. The first stage presents with flulike symptoms and erythema chronicum migrans, which is a macular rash with an outer ring of erythema and a central area of clearing, often referred to as a "bulls-eye rash". The second stage presents with neurologic (Bell's palsy) and cardiac (AV nodal block) manifestation. The third stage presents with chronic monoarthritis and migratory polyarthritis. Of the ECG findings described above, prolonged PR interval is seen in AV nodal block.

A 30-year-old man presents for evaluation of recurrent nosebleeds, black stool, and persistent red discolorations on his lips and skin. He has a younger sister with similar symptoms. His wife is currently pregnant, and he wants to know what the chances are that his child will inherit this illness. What is the most appropriate thing to tell him?

The patient most likely has hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome). It is inherited in an autosomal-dominant manner; therefore, the patient's child has a 50% chance of inheriting this disorder. The common clinical manifestations of this disorder are recurrent epistaxis, skin discolorations, mucosal telangiectasia, and gastrointestinal bleeds. The underlying pathophysiology of this disorder is caused by arteriovenous malformations of the small vessels.

A 15-year-old male presents to the emergency department after he suddenly fainted while he was competing at basketball tournament. He is awake and conscious soon after he arrives at the emergency department and is able to inform the physician of his past medical history. He has no significant illnesses and is currently not taking any medication. Upon questioning, he admits to having tried using marijuana and "some other stuff" with his friends last week. He denies having ever fainted before. Family history is significant for an uncle who passed away in his mid-20s from a heart attack. Physical examination shows a well-built young man in no apparent distress. Cardiac exam reveals a 3/6 holosystolic murmur at the apex. Other parts of the physical examination are unremarkable. What is the most likely cause of the murmur?

The patient most likely has hypertrophic cardiomyopathy, which can cause a holosystolic murmur at the apex due to mitral regurgitation, which is a result of systolic anterior motion of the mitral valve and significant LV outflow gradient. Anatomically, the LV outflow tract obstruction is located between the septum and the anterior leaflet of the mitral valve. The significant gradient is a result of the hypertrophied interventricular septum being "too close" to the mitral valve. In addition to syncope, the other common presentation of hypertrophic cardiomyopathy is difficulty breathing. A biopsy of the affected cardiac tissue would show disoriented, tangled and hypertrophied myocardial fibers.

A 70-year-old man is brought to the emergency room by his family after he reports feelings of chest pain, palpitations, and lightheadedness. His son informs the physician that even though his father has been in "pretty good" health, he does report feeling more fatigued than usual. Workup for myocardial infarction is mostly negative. Below is his EKG

The patient most likely has sick sinus syndrome, which can present with chest pain, confusion, fainting, fatigue, dizziness, palpitation and shortness of breath. It is a condition that develops over time and is caused by the inability of the sinoatrial (SA) to function as the pacemaker of the heart. The symptoms of sick sinus syndrome are mostly due to decreased cardiac output (i.e. fainting caused by low perfusion to the brain). It most commonly affects the elderly and is often idiopathic. The EKG may be normal, or may show sinus bradycardia, sinoatrial block and alternating tachycardia/bradycardia. The current EKG shows bradycardia at around 46 beats per minutes. Thus it is also known as Tachy/Brady Syndrome

A 38-year-old female presents for evaluation of night sweats, joint pain and fatigue. She had previously been very healthy. However, she has noticed that her menstrual cycle has become more irregular and that she has had a rash. She denied being sexually active for the past year. Review of systems was mostly negative. During the physical examination, the physician notes weak radial and brachial pulses. What is the most likely diagnosis?

The patient's clinical presentations are most consistent with Takayasu's arteritis. Takayasu's arteritis is a condition that most often affects female patients in their middle age. Symptoms include constitutional symptoms such as fever and fatigue, arthritis, headache, and rash. On examination, patients with Takayasu's arteritis often have weak pulses in their upper extremities due to granulomatous thickening of aortic arch.

A 40-year-old man with poorly managed HIV presents to the emergency department with sudden onset of dyspnea, dizziness and palpitation. Physical examination shows a blood pressure of 90/60 mm Hg, respiratory rate of 30/min, distant heart sounds, and increased jugular venous pressure. The physician also notices that the systolic pressure decreased by 15 mmHg during inspiration and that patient's skin is cold and clammy. No edema is observed. What is the most likely diagnosis?

The patient's condition is most likely caused by acute cardiac tamponade. Beck's triad for acute cardiac tamponade is hypotension, increased jugular vein pressure, and distant heart sounds. The patient is also showing pulses paradoxus (decreased in the amplitude of pulse during inspiration), which is consistent with cardiac tamponade. As a result of impaired systemic venous return, there may also be equilibration of diastolic pressure in all 4 chambers and a decrease in cardiac output. The patient's tachypnea is likely due to his trying to compensate for the decreased cardiac output. In addition to radiation therapy, other causes of cardiac tamponade include HIV infection, drug-induced systemic lupus erythematosus (SLE), and uremia. Given the acute nature of the patient's clinical presentations, acute tamponade is the most likely diagnosis.

A 25-year-old man presents to the emergency department with fever and joint pain. He denies having any significant medical illness. He notes having occasional joint pain in the past that he treated with over the counter analgesics. He rarely exercises because of difficulty breathing. He is a thin young man in mild distress. Cardiac exam reveals a murmur characterized by an opening snap, followed by a late rumbling diastolic murmur. Further laboratory evaluation shows an elevated erythrocyte sedimentation rate. Where is the most likely location of the cardiac abnormality causing the patient's symptom?

The patient's symptoms and findings (fever, joint pain, elevated ESR, prominent a wave) are most likely due to rheumatic heart disease, which can occur after pharyngeal infection with group A beta-hemolytic streptococci. The mitral valve is most commonly affected, but the aortic and tricuspid valve lesions may also occur (mitral > aorta > tricuspid). The description of the murmur is consistent with mitral stenosis.

A 73-year-old Caucasian man presents to his family physician for a routine physical examination. He feels healthy and has no complaints. Temperature is 37°C (98.6°F), blood pressure is 134/85, heart rate is 82 beats/minute, and respiratory rate is 17 breaths/minute. The cardiac exam reveals a grade III/VI crescendo-decrescendo systolic murmur, best heard over the right second intercostal space. Radial pulses are 2+ bilaterally. The remainder of the exam is within normal limits. Which of the following would be an indication for surgical intervention in this patient?

This patient displays the classic murmur of aortic stenosis. Aortic stenosis becomes more common with age, which also makes the diagnosis more likely in this patient. Several etiologies are possible; one of the most common is age-related calcification of the aortic valve. Aortic stenosis is more common in patients with congenital bicuspid aortic valves. Severe obstruction can impair blood flow across the valve. The development of symptoms from this impaired flow—angina, presyncope, syncope, or heart failure—is associated with sudden cardiac death and therefore an indication for valve replacement.

A 47-year-old man presents to the hospital for evaluation of sudden onset right eye pain and redness. He denies any trauma to the area. He complains of worsening pain when looking into the light, tearing and blurred vision in his right eye. His past medical history is only remarkable for chronic lower back and hip pain that began in his early 20s. He describes the back pain as usually worse at night or in morning when he is not active, however, it decreases with exercising. During the physical examination, he is noted to be hyperkyphotic and on cardiac auscultation the physician detects a soft, high-pitched early diastolic murmur. A radiograph of the spine is below.

This patient most likely has ankylosing spondylitis, a type of seronegative (rheumatoid factor negative) spondyloarthropathy of the sacroiliac joint and axial skeleton. One of the so-called "PAIR" spondyloarthropathies associated with the HLA-B27 gene - the group includes psoriatic arthritis, ankylosing spondylitis, inflammatory bowel disease and reactive arthritis - ankylosing spondylitis has a clinical presentation which involves three key features His past medical history and spine radiograph clues you in to the ankylosing spondylitis diagnosis. Finally, and most importantly here, his soft, high-pitched early diastolic murmur represents the murmur of aortic regurgitation which again would be the most likely murmur in a patient with ankylosing spondylitis. However, this is typically a rare finding and often indicates that the patient is late in the disease - not surprising considering that the onset of ankylosing spondylitis is usually in the 20s and this patient is 47 years old.

A 55-year-old man presents to the emergency department with altered mental status. He is a homeless man who was found sleeping in a mechanic's garage this morning. He is somnolent and taking deep, rapid breaths. His laboratory tests show normal glucose levels and no evidence of acetaminophen or salicylates. There is a metabolic acidosis. Urine testing shows envelope shaped crystals. Which of the following findings would be most likely seen on this patient's EKG?

This patient most likely has ingested ethylene glycol, which is found in radiator fluid. Poisonings are known to occur in children (because ethylene glycol is sweet), accidental work-related ingestions, and suicide attempts. Most likely, this patient accidentally drank anti-freeze that was in the automotive garage. Ethylene glycol is metabolized by alcohol dehydrogenase to produce glycolic acid. Buildup of glycolic acid produces metabolic acidosis, which explains this patient's compensatory rapid breathing. Glycolic acid is metabolized subsequently to glyoxylate acid, which can form oxalate. Oxalate forms crystals along with calcium, and calcium oxalate can damage the kidney. Calcium oxalate crystals are classically described as appearing like envelopes upon examination of urine sediment. Excess amounts of oxalate bind up calcium in the blood, resulting in hypocalcemia. Hypocalcemia presents on EKG with QT prolongation.

A 50-year-old man presents for an evaluation of fever, muscle aches, abdominal pain, and recent weight loss. Examination reveals a lacy, non-blanching rash on the extremities. Laboratory test shows elevated erythrocyte sedimentation rate. Biopsy and angiogram are performed and confirms the diagnosis. His symptoms improved after receiving treatment of corticosteroids and cyclophosphamide. Which below is the most appropriate description of the findings on biopsy and angiogram?

This patient most likely has polyarteritis nodosa (PAN). PAN is an immune complex-mediated transmural vasculitis that can present with non-specific gastrointestinal complaints, fever, arthralgias, myalgias, weight loss, and dermatologic complaints. Biopsy of the affected vessels show fibrinoid necrosis, and arteriogram usually shows multiple aneurysms and constrictions. This condition normally affects small and medium-sized arteries, particularly the renal and visceral vessels. Pulmonary arteries are rarely affected.

A 56-year-old man with type 2 diabetes mellitus, hypertension, and asthma presents with acute onset chest pain and a temperature of 38.6°C. The pain is non-radiating, constant, and exacerbated with lying down. Cardiac examination reveals a faint heart sound during both systole and diastole. Serum CK-MB and troponin levels are within normal limits. Which of the following would most likely be seen in the EKG?

This patient most likely presents with acute pericarditis as indicated by the positional nature of his chest pain. Pericarditis is most commonly idiopathic, but coxsackie virus infection is also a well-known cause. It may present with fever and a pericardial friction rub which is best heard with the patient leaning forward. EKG will classically show ST elevations in all leads. Treatment is with NSAIDs.

A 56-year-old man is brought to the hospital after fainting. Vital signs taken in the ambulance show a blood pressure of 61/34 mm Hg and pulse of 143 beats/minute. On examination, he has a loud holosystolic murmur at the base of the heart. Despite resuscitation measures, he dies. Which of the following is most likely true about this patient?

This patient most likely presents with rupture of the interventricular septum. Patients with rupture of the septum usually present with sudden onset of hemodynamic compromise, heart failure, and a harsh holosystolic murmur. This is a known complication of myocardial infarction, occurring as early as 24 hours or as late as 2 weeks following myocardial infarction. Most commonly, this occurs three to five days following infarction. This complication most commonly occurs in patients that had a myocardial infarction involving the septum.

A 30-year-old man presents to the emergency department for evaluation of chest pain. He has previously been very healthy. During his last visit to the physician a few months ago, he received the flu vaccine and tested negative for HIV. Physical exam reveals a well-built young man in distress with a heart rate of 100 beats per minute and a blood pressure of 90/60. Cardiac exam shows a pericardial friction rub and distant heart sounds. The physician also notices a drop in systolic pressure during inspiration. EKG shows ST-segment elevation in multiple leads. After evaluating the signs and symptoms and patient's past medical history, the physician believes the patient's condition is most likely due to a viral infection. This same virus can cause what other disease?

This patient presents with symptoms consistent with acute pericarditis. He has a pericardial friction rub, distant heart sounds, pulsus paradoxus, and diffuse ST segment elevation on EKG. The virus is most likely Coxsackie B, an enterovirus that is the most common cause of viral pericarditis. Coxsackie B virus can also cause dilated cardiomyopathy. Other causes of dilated cardiomyopathy include chronic cocaine use, Chagas' disease, doxorubicin toxicity, hemochromatosis and peripartum cardiomyopathy.

A 58-year-old man presents to his primary care provider for an insurance physical. His blood pressure is 137/81, heart rate is 76/min, temperature is 37ºC (98.7ºF), and respiratory rate is 14/min. He has a history of hypertension treated with hydrochlorothiazide and type 2 diabetes mellitus treated with metformin. His physical examination is unremarkable. Fasting laboratory results are shown below. LDL cholesterol 151 mg/dL HDL cholesterol 39 mg/dL Triglycerides 320 mg/dL

This patient's LDL level is elevated above the goal of 100 mg/dL given his history of diabetes mellitus. If the patient had known coronary artery disease or prior cerebrovascular accident or transient ischemic attack, the goal LDL would be 70 mg/dL. In addition to diet and exercise, pharmaceuticals can decrease LDL levels. HMG-CoA reductase inhibitors, also called statins, inhibit the rate-limiting step in cholesterol synthesis and are extremely effective at lowering LDL cholesterol; therefore, they are first-line agents for treatment of elevated LDL cholesterol. They also mildly increase HDL cholesterol and decrease triglycerides. One of the most feared side effects of statins is rhabdomyolysis, but this is not a common side effect. Myalgias and hepatotoxicity are more common side effects.

This patient presents complaining of the classic uveitis symptoms described above. A 35-year-old African American man presents to an urgent care center with palpitations. He also complains of episodic headaches and nausea. Physical examination reveals an anxious man with obvious diaphoresis and trembling extremities. His blood pressure is 220/130 upright and 170/100 supine, with a heart rate of 120 beats per minute. Family history includes a sister with thyroid cancer.

This patient's symptoms are consistent with a pheochromocytoma: a rare tumor of the adrenal medulla which hypersecretes epinephrine and norepinephrine. Symptoms of a pheochromocytoma include life-threatening hypertension (sustained and/or paroxysmal), orthostatic hypotension, headache, diaphoresis, palpitations, nausea and vomiting, trembling, and anxiety. Some familial syndromes are associated with pheochromocytomas, including multiple endocrine neoplasia type IIa and IIb (MEN IIa and IIb). Both of these syndromes are associated with pheochromocytomas and medullary thyroid carcinoma, so this patient's family history would also make a physician suspicious for a pheochromocytoma. The end products of epinephrine and norepinephrine metabolism are metanephrine, normetanephrine, vanillylmandelic acid, and homovanillic acid. All of these are found in the urine, are highly elevated in patients with pheochromocytomas, and are good screening tests for pheochromocytomas.

Torsadws tx

While often self-limiting, the initial treatment of choice for patients in a Torsades rhythm is intravenous magnesium. Magnesium treats the arrhythmia by decreasing calcium influx into cardiac cells. This treatment also corrects the hypomagnesemia often seen in patients presenting with Torsades rhythms. Definitive treatment involves removing the offending agent, which would be the antipsychotic ziprasidone in this patient.

Sick Sinus Syndrome

affects approximately 1 in 600 patients over the age of 65. It also accounts for nearly 50% of pacemaker implantation. The treatment of choice for sick sinus syndrome is a dual chambered pacemaker. In addition to sick sinus syndrome of unknown cause, external causes of sick sinus syndrome include hyperkalemia, hypoxia, digitalis preparations, calcium channel blockers, beta blockers, sympatholytic agents, anti-arrhythmic medications and toxins. Intrinsic causes include: cardiomyopathies, familial tendencies, leukemia, metastatic cancer, myocarditis, pericarditis, rheumatic heart disease and surgical injury.

Kawasaki disease

is the leading cause of acquired heart disease in children under 5 years old in the United States. Echocardiography should be done to evaluate for coronary artery dilation, which may be seen in up to 25% of children with Kawasaki disease. The coronary artery dilation may eventually lead to cardiovascular sequelae such as aneurysm formation with thrombosis, myocardial infarction, and sudden death. Treatment with IVIG and aspirin for their anti-inflammatory effects have been shown to reduce the risk of these events. Reye syndrome is a potentially fatal disease seen in children who take aspirin and have an influenza or varicella infection. Generally, aspirin is contraindicated in children due to Reye syndrome, but Kawasaki disease is one of the extremely few indications where aspirin is given to minors. Reye syndrome is characterized as an acute noninflammatory encephalopathy and hepatic failure. Therefore, hepatic encephalopathy would be the most likely complication of this patient, who is taking aspirin, if he becomes infected with either varicella or influenza