Main cardiology study guide part 3

What is the most common cause of tricuspid stenosis? A Rheumatic fever B Infective endocarditis C Congenital heart defects D Coronary artery disease E Hypertension

A Rheumatic fever

A patient had an acute inferior, transmural myocardial infarction 4 days ago. A new murmur raises the suspicion of mitral regurgitation due to papillary muscle rupture. Which of the following murmur descriptions describes this condition? A A grade III/VI diastolic murmur heard best at the apex without radiation. B A grade IV/VI systolic ejection murmur heard best at the base with radiation to the left clavicle. C A grade II/VI systolic murmur heard best at the apex preceded by a click and without radiation. D A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.

A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.

A 9-year old girl is brought to the clinic by her mother on account of fever. She has red skin lesions on the trunk and proximal extremities, and also small, non-tender lumps located over the joints. On further enquiry, she reports a history of sore throat which occurred about 4 weeks ago. Which of the following would you do to support the diagnosis of acute rheumatic fever? A Erythrocyte sedimentation rate (ESR) B Antinuclear antibodies C White blood cell count D Anti-streptolysin O titer

Anti-streptolysin O titer

S3 or S4 with severe; water-hammer pulse (arterial pulse large and bounding)

Aortic Regurgitation:

___soft high pitched, blowing, crescendo-decrescendo along left sternal border; loud leaning forward/squatting

Aortic Regurgitation:

__harsh systolic ejection crescendo-decrescendo at the right upper sternal border with radiation to neck and apex

Aortic Stenosis:

___ flank pain, hypotension, pulsatile abdominal mass; screen if male >65 and hx of smoking

Aortic aneurysm:

___sudden onset tearing chest pain between scapula; diminished pulses; widened mediastinum; unequal blood pressures on the arm

Aortic dissection:

Diastolic Murmurs

Aortic regurgitation Mitral stenosis Pulmonary regurgitation: Tricuspid stenosis

___soft, high pitched, blowing diastolic along LSB with pt sitting, leaning forward after exhaling

Aortic regurgitation:

An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis? A Aortic stenosis B Aortic regurgitation C Mitral stenosis D Mitral valve prolapse

Aortic stenosis The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area.

__ systolic ejection crescendo-decrescendo RUSB

Aortic stenosis:

sudden arterial occlusion Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia

Arterial embolism/thrombosis:

A 24 y/o waitress complains of generalized, sub-sternal chest pain that is worsened with exertion. She appears anxious; she denies ETOH, tobacco and illicit drug use. You auscultate her heart and diagnose MVP. What did you hear to make this diagnosis? A A diastolic rumble B A holosystolic click C A midsystolic click D An opening snap

C A midsystolic click

Severe disease: ulceration (stasis ulcer, dermatitis) - PAINLESS

Chronic Venous Insufficiency

Symptoms: progressive edema, itching, dull pain, ulcerations Signs: shiny, thin, atrophic skin

Chronic Venous Insufficiency

Pharmacologic management of peripheral arterial disease includes: A Elastic compression stockings B Calcium channel blockers C Cilostazol D Warfarin E Propranolol

Cilostazol Cilostazol (a phosphodiesterase inhibitor) increases claudication distance by 40% to 60% in patients with peripheral arterial disease. Elastic compression stockings should be avoided as it can decrease arterial circulation to the skin. Calcium channel blockers have not proven to be beneficial. Warfarin may prevent more cardiovascular events but causes more major bleeding and has not been shown to improve outcomes in those with chronic PAD.

What is the most common cause of pulmonary valve stenosis? A Rheumatic fever B Infective endocarditis C Congenital heart defects D Coronary artery disease E Hypertension

Congenital heart defects

How does the murmur of mild aortic regurgitation differ from that of severe aortic regurgitation (AR)? A Mild aortic regurgitation is high pitched and severe aortic regurgitation is low pitched B Mild aortic regurgitation is crescendo and severe aortic regurgitation is decrescendo C The intensity of the murmur is louder in severe aortic regurgitation D Severe aortic regurgitation is shorter in duration compared to mild aortic regurgitation

D Severe aortic regurgitation is shorter in duration compared to mild aortic regurgitation

varicose veins diagnosis

Diagnostics: duplex ultrasonography

a 55-year-old obese Caucasian gentleman who arrives at your clinic for a routine check-up after having some blood work done during a routing workplace health screening. He is found to have a total cholesterol level of 430 mg/dL. He complains of calf pain while walking to the convenience store, which only resolves with rest. He states that he has a follow-up appointment with his cardiologist because of some occasional chest pain and abnormalities seen on his EKG. Additionally, you notice that he has well-demarcated yellow deposits around his eyes.

Hyperlipidemia

a 22-year-old female who complains of generalized, sub-sternal chest pain that is worsened with exertion. She appears anxious; she denies ETOH, tobacco, and illicit drug use. You auscultate her heart and hear a midsystolic click. The murmur is noticeably longer and often louder with standing and Valsalva.

Mitral valve prolapse

___ midsystolic ejection click at the apex

Mitral valve prolapse:

A 19-year-old basic training cadet presents with 3 days of pain in his right hand and forearm after having an IV placed for hydration following an intense training exercise. Examination is significant for a warm, palpable cord originating on the dorsum of the right hand; there is no associated cellulitis or purulence. A Doppler examination reveals thrombosis of the cephalic vein without extension into the deep veins. Which of the following is the most appropriate next step in management? A Heparin B Warfarin C Nonsteroidal anti-inflammatory drugs D Antibiotics

Nonsteroidal anti-inflammatory drugs

high pitched early diastolic decrescendo murmur at LUSB that increases with inspiration

Pulmonary Regurgitation:

harsh, loud, medium pitched systolic murmur heard best at 2nd/3rd left intercostal space that may increase with inspiration

Pulmonary Stenosis:

What is the most common cause of pulmonary regurgitation? A Rheumatic fever B Congenital heart defects C Pulmonary hypertension D Acute myocardial infarction E Chronic obstructive pulmonary disease (COPD)

Pulmonary hypertension

a 24-year-old male with dyspnea on exertion. Physical exam reveals a high-pitched diastolic decrescendo murmur at the LUSB that increases with inspiration.

Pulmonary regurgitation

___ high pitch, decrescendo murmur at LUSB, increases with inspiration

Pulmonary regurgitation:

a 25-year-old male who presents to the clinic complaining of mild dyspnea on exertion. Examination reveals a prominent jugular pulsation and a palpable parasternal lift. There is a harsh systolic murmur best heard at the second and third left intercostal space; it radiates to the left shoulder. An early systolic sound precedes the murmur during expiration. ECG demonstrates right-axis deviation

Pulmonary stenosis

__ hard midsystolic ejection crescendo-decrescendo murmur with widely split S2 at LSB that radiates to left shoulder and neck

Pulmonic stenosis:

A 29-year-old female college soccer coach presents with anxiety, fatigue, and insomnia. The symptoms began after a heart murmur was discovered on her preemployment physical. An echocardiogram revealed mild MVP. A male athlete at her school recently died suddenly on the playing field because of undiagnosed idiopathic hypertrophic cardiomyopathy, and she is afraid she will die in a similar manner. She is anxious, sleepless, and fearful of physical activity. Your physical exam is normal and her EKG shows no abnormalities. Which one of the following would be most appropriate at this point? A Reassurance regarding the benign course of her condition B Stress test C Clonazepam D Referral to a cardiologist E Referral for group psychotherapy

Reassurance regarding the benign course of her condition

A 37-year-old female with a 10-year history of amyloidosis complains of progressive weakness, fatigue, abdominal fullness, and pedal edema progressive over the last month. She denies any recent illness. On physical examination, the patient has positive jugular venous distention, pitting edema of bilateral lower extremities, and hepatomegaly with mild tenderness to palpation. On auscultation a holosystolic murmur is heard at the left sternal border that increases with inspiration. What is the most likely diagnosis? A Cor pulmonale B Cardiac tamponade C Restrictive cardiomyopathy D Infectious myocarditis

Restrictive cardiomyopathy

Which of the following is associated with acute rheumatic fever A Manning criteria B Revised Jones criteria C Ranson criteria D Duke criteria

Revised Jones criteria

a 30-year-old woman presents with 2 weeks of arthralgias, migrating from distal to proximal joints. It began with increased warmth and erythema in her right ankle and left knee. She has a low-grade fever and reports a history of sore throat and swollen glands about 1 month ago. On physical exam she has red skin lesions on the trunk and proximal extremities, and also small, non-tender lumps located over the joints. Antistreptolysin O titer is positive.

Rheumatic fever

___is a consequence of rheumatic fever characterized by inflammation and scarring of the heart valves

Rheumatic heart disease

A 55-year-old female presents with shortness of breath, fatigue, and leg swelling. Physical examination reveals elevated jugular venous pressure and hepatomegaly. An echocardiogram shows moderate to severe tricuspid stenosis. What are the clinical signs and symptoms of moderate to severe tricuspid stenosis? A Left ventricular hypertrophy and S3 gallop B Right ventricular hypertrophy and S3 gallop C Left ventricular hypertrophy and S4 gallop D Right ventricular hypertrophy and S4 gallop

Right ventricular hypertrophy and S3 gallop

What is the most common symptom of pulmonary valve stenosis? A Chest pain B Shortness of breath during physical activity C Fatigue D Swelling in the legs, ankles, or feet E Rapid or irregular heartbeat

Shortness of breath during physical activity

A 37 year-old female with history of Turner's syndrome and coarctation of the aorta repaired at the age of 3 presents for routine examination. The patient is without complaints of chest pain, dyspnea, palpitations, or syncope. On examination vitals signs reveal a BP of 130/76, HR 70, regular, RR 16. On cardiac examination you note a grade II/VI systolic ejection murmur at the left sternal border and a grade III/VI blowing diastolic murmur. Which of the following does this patient require? A antibiotic prophylaxis B beta blocker therapy C chest CT D exercise stress test

antibiotic prophylaxis This patient has a history of congenital heart disease and presently has a murmur consistent with aortic regurgitation. This patient requires antibiotic prophylaxis against infective endocarditis.

a 61-year-old male presents with a recent history of increased fatigue with mildly increased exertional dyspnea. Patient denies any significant past medical history but states that he had some heart problems as a child, though he was never clear as to what was the problem. On cardiac examination, you hear an early diastolic, soft blowing decrescendo murmur with a high pitch quality, especially when the patient is sitting and leaning forward. No thrill is felt.

aortic regurgitation

a 59-year-old male with chest pain, dyspnea, and presyncope. The symptoms occurred after climbing a flight of stairs. He has a late systolic-ejection murmur (SEM) heard in the second intercostal space (ICS) at the right sternal border with radiation to the carotids and the apex. A prominent S4 is noted at the apex. The lungs are clear. Examination of the extremities shows mild pedal edema bilaterally. The murmur is decreased with Valsalva maneuver. EKG is suggestive of LV hypertrophy.

aortic stenosis

systolic murmurs

aortic stenosis mitral regurgitation Tricuspid regurgitation mitral valve prolapse

Peripheral vascular disease diagnosis __ is the gold standard (clinically only done if revascularization is planned); Additionally you can do __

arteriography Doppler ultrasonography ankle-brachial-index (ABI) < 0.9

Endocarditis treatment

aspirin / NSAID, steroid, Antistreptococcal prophylaxis - PENICILLIN G

cause of aortic stenosis

congenital bicuspid valve or increased calcification with age

A 28-year-old female from Bangladesh is brought to the United States for evaluation and repair of a heart valve problem. Since having a febrile illness with sore throat and skin rash at age 23 years, she has been experiencing increasing exhaustion, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Physical exam reveals an opening snap just after S2 and a low-pitched diastolic murmur heard best at the apex. CXR demonstrates an enlarged left ventricle. What is the most likely diagnosis? A aortic regurgitation B mitral stenosis C pulmonic regurgitation D tricuspid stenosis

mitral stenosis Mitral stenosis is common after rheumatic fever. The murmur and opening snap are as described.

midsystolic ejection click heard best at the apex

mitral valve prolapse

a 45-year-old female with a long history of a heart murmur with one week of increasing fatigue and low-grade fevers. She had a dental cleaning two weeks ago. She denies any hematuria, neurological symptoms, or changes in the appearance of her hands and fingernails. Her past medical history is otherwise insignificant. On physical exam, her temperature is 38.1 C (100.6 F), heart rate is 92/min, blood pressure is 118/67, and respiratory rate is 16/min. She appears fatigued but in no acute distress. Cardiac auscultation reveals a grade III/VI holosystolic murmur heard best at the cardiac apex in the left lateral decubitus position. Pulmonary, abdominal, and extremity exams are within normal limits. An echocardiogram is performed and is shown here. The patient is admitted and started on empiric IV antibiotics. Three days later, 4/4 blood cultures grow Streptococcus viridans that is highly sensitive to penicillin.

Acute and subacute bacterial endocarditis

___ = gold standard for Arterial embolism/thrombosis:

Angiography

A 72-year-old smoker with a positive history of severe degenerative arthritis, diabetes, and CVD presents to your office complaining of bilateral leg pain that occurs after walking 200 yards. He reports that rest improves his symptoms. Which of the following would be appropriate? A Ankle/ brachial indices B MRI of the lumbar spine C Ultrasonography of the lower extremities D EMG of the lower extremities E Arteriogram of the lower extremities

Ankle/ brachial indices

A 65-year-old woman presents to the emergency department with worsening dyspnea, fatigue, and abdominal distension. She has a history of rheumatic fever in childhood and mitral valve replacement 10 years ago. On physical examination, she has jugular venous distension, hepatomegaly, ascites, and peripheral edema. Her blood pressure is 110/70 mmHg, pulse is 90 beats per minute and irregularly irregular, respiratory rate is 22 breaths per minute, and oxygen saturation is 95% on room air. An electrocardiogram shows atrial fibrillation with a ventricular rate of 90 beats per minute. A chest radiograph shows cardiomegaly and pulmonary congestion. A transthoracic echocardiogram reveals severe tricuspid stenosis with a mean gradient of 8 mmHg and a valve area of 0.8 cm2. What is the most appropriate initial management for this patient? A Anticoagulation therapy B Diuretic therapy C Percutaneous balloon valvuloplasty D Surgical tricuspid valve replacement E Transcatheter tricuspid valve implantation

Diuretic therapy

__ is pericarditis 2-5 days after an acute myocardial infarctions

Dressler's syndrome

A 65 year-old white female presents with dilated tortuous veins on the medial aspect of her lower extremities. Which of the following would be the most common initial complaint? A Pain in the calf with ambulation B Dull aching heaviness brought on by periods of standing C Brownish pigmentation above the ankle D Edema in the lower extremities

Dull aching heaviness brought on by periods of standing

Which of the following is not a major criterion for diagnosing acute rheumatic fever? A Carditis B Polyarthritis C Chorea D Erythema marginatum E Elevated C-reactive protein (CRP) levels

Elevated C-reactive protein (CRP) levels

A 76-year-old male with a 5 year history of atrial fibrillation presents to the Emergency Department with an inability to move his left leg. The patient notes that he first noted that his leg "felt funny" about two hours ago, and that it appeared to be more pale than normal. Since the leg started feeling funny, his ability to move it has decreased, to the point where he can no longer move it. He recently ran out of his warfarin, and hasn't taken any in two weeks. On physical exam his vital signs are within normal limits. His neurological exam reveals a pale, painful left leg with absent femoral and dorsalis pedis pulses. He has no other strength deficits and pulses in his right leg and right arm are intact. Which of the following would be the appropriate first action for this patient's condition? A Thrombolysis B Embolectomy C Fasciotomy D Amputation E No intervention necessary

Embolectomy This patient has an embolic occlusion of his left common iliac artery resulting in the pale, painful leg. The appropriate intervention would be an embolectomy to try and remove the occlusion. Patients with atrial fibrillation are at risk for embolic complications, especially patients who abruptly discontinue their anticoagulation. Embolic complications can include stroke or other systemic embolizations. An embolism to the common iliac artery results in a pale, pulseless, painful leg, and requires immediate embolectomy to preserve the limb.

endocarditis most common bugs Endocarditis with intravenous drug users Endocarditis with prosthetic valve -

Endocarditis with intravenous drug users - Staphylococcus aureus Endocarditis with prosthetic valve - Staphylococcus epidermidis

Janeway lesions are painful lesions on the hands? A True B False

False

Amaurosis fugax (temporary monocular blindness) secondary to anterior ischemic optic neuritis associated with

Giant cell arteritis

inflammation of large and medium vessels - jaw claudication and HA, thickened temporal artery scalp pain elicited by touching scalp/hairbrush; acute vision disturbances; associated with polymyalgia rheumatica

Giant cell arteritis:

__ medium-pitched, mid-systolic murmur that decreases with squatting and increases with strainingS4 gallop and apical lift with a thick, stiff left ventricle

HCOM

Endocarditis Empiric treatment: Prosthetic valve: High-Risk patients prophylaxis for procedures:

IV vancomycin or ampicillin/sulbactam PLUS aminoglycoside Prosthetic valve: Add rifampin High-Risk patients-Amoxicillin

What is the main physiological effect of pulmonary regurgitation on the right ventricle? A Decreased contractility B Increased stroke volume C Decreased end-diastolic volume D Increased end-systolic volume E Increased cardiac output

Increased end-systolic volume

varicose veins treatment

Interventions: exercise programs, elevation, radiofrequency or laser ablation, compression, sclerotherapy, surgical stripping

Locations of Myocardial infarctions Location: Anterior wall Inferior wall: Lateral wall: Posterior wall:

Location:Anterior wall - STE in leads I, AVL, V2-V6 Inferior wall: II, III, AFV Lateral wall: lateral leads - I, AVL, V4-6 and reciprocal STD in inferior leads Posterior wall: ST depression in V1-3

chronic venous insufficiency treatment

Management: prevention, elevation, avoid extended standing or sitting, compression hose Interventions: wet compresses, compression boots or stockings, skin grafting

treatment Phlebitis

Management: superficial: bed rest, local heat, elevation, NSAIDs; deep = anticoagulation (prevention is key!!) Interventions: surgery

treatment for peripheral vascular disease

Medications: B-blocker, ACE-I, statins Platelet inhibitors: cilostazol = mainstay of treatment (helpful for intermittent claudication) aspirin clopidogrel (Plavix) Revascularization: Angioplasty → Fem-pop bypass → Endarterectomy TX: aspirin, cilostazol, rosuvastatin, smoking cessation, structured exercise

___blowing holosystolic murmur at the apex with split S2 radiating to the left axilla

Mitral Regurgitation:

__diastolic low pitched decrescendo rumbling with an opening snap heart best at the apex with pt. lying lateral decubitus position

Mitral Stenosis:

a 64-year-old obese man with a history of hyperlipidemia and poorly controlled type 2 diabetes underwent percutaneous transluminal coronary angioplasty of the posterior descending artery 3 days ago for an ST-elevation myocardial infarction. He has so far been stable since this procedure, but overnight you are called to his bedside. He is pallid and breathing laboriously. Notable vital signs include a blood pressure of 85/45 mmHg with a heart rate of 125 beats per minute. His lung exam is notable for bibasilar crackles. On cardiac exam, you note a hyperactive precordium with a new III/VI blowing holosystolic murmur at the apex (mitral area) with a split S2 that radiates to the axilla.

Mitral regurgitation

__blowing holosystolic murmur at the apex with a split S2

Mitral regurgitation: blowing holosystolic murmur at the apex with a split S2

___ diastolic low pitched decrescendo and rumbling with opening snap at apex

Mitral stenosis:

__ is atherosclerotic disease of the lower extremities (and vessels outside the heart and brain)

Peripheral artery disease

a 63-year-old male complaining of bilateral leg pain, which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. Past medical and surgical history is significant for hypertension, hyperlipidemia, and coronary artery bypass graft (5 years ago). He has a 60-pack-year smoking history. Vital signs are as follows: Temp 37C, HR 70, BP 143/89, and RR 18. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally; they are warm and well perfused. Ankle-brachial indices are 0.7 and 0.8

Peripheral artery disease

intermittent claudication reproducible pain/discomfort in lower extremity brought on by exercise with exercise and relieved with rest; erectile dysfunction

Peripheral vascular disease

Sx: superficial = dull pain, erythema; deep = swelling, heat, redness Signs: superficial = erythema, tenderness, induration; deep = heat, edema, Homan's sign (calf pain w foot dorsiflexion)

Phlebitis

a 49-year-old male who is being evaluated for pain and swelling of his right lower extremity. He noticed his calf appears red and denies any trauma to the affected area. A week prior to presentation, he was on a plane for over 13 hours. Medical history is significant for venous insufficiency. On physical exam, there is erythema on the posterior calf and tenderness along the course of a superficial vein. A duplex ultrasound demonstrates impaired blood flow and incompressibility of a superficial vein.

Phlebitis/thrombophlebitis

acute arterial embolism symptoms

The 6 P's caused by acute arterial embolism: pain, pulselessness, pallor, paresthesias, poikilothermia (inability to regulate temperature), paralysis

__ harsh holosystolic murmur heard at LSB with wide radiation and fixed, split S2

Ventricular septal defect

A 60-year-old female recently discharged after an 8 day hospital stay for pneumonia presents complaining of pain and redness in her right arm. The patient thinks this was the area where her IV was placed. The patient denies fever or chills. Examination of the area reveals localized induration, erythema and tenderness. There is no edema or streaking noted. Which of the following is the most likely diagnosis? A Acute thromboembolism B Thrombophlebitis C Cellulitis D Lymphangitis

Thrombophlebitis

high pitched holosystolic murmur at LLSB radiates to the sternum and increases with inspiration

Tricuspid Regurgitation:

mid-diastolic rumbling murmur at LLSB with opening snap

Tricuspid Stenosis:

A 27-year-old male with a remote history of endocarditis secondary to intravenous drug use presents with complaints of abdominal fullness and edema. On examination, he has jugular venous distention, hepatic congestion, and peripheral edema. A blowing holosystolic murmur is heard along the lower left sternal border than is intensified with inspiration. What is this murmur? A Tricuspid regurgitation B Mitral regurgitation C Aortic stenosis D Mitral stenosis

Tricuspid regurgitation

a 73-year-old man with a history of rheumatic fever and coronary atherosclerosis who presents to the emergency department with dyspnea on exertion and orthopnea. He called 911 because he could not catch his breath. On examination, he was found to have jugular venous distention (JVD), hepatic congestion, and peripheral edema. On physical examination, you note a blowing holosystolic murmur along the left sternal border that is intensified during inspiration. Atrial fibrillation is noted on his ECG.

Tricuspid regurgitation

__ high pitched holosystolic murmur at mid-LSB

Tricuspid regurgitation:

a 55 y/o-male presents with a chief complaint of shortness of breath on exertion. On physical examination, you note a diastolic rumbling murmur heard best at the left lower sternal margin and the xiphoid, augmented during inspiration. The exam is also notable for JVD and pedal edema. An echocardiogram reveals right atrial enlargement.

Tricuspid stenosis

__ mid-diastolic rumbling at LLSB with opening snap

Tricuspid stenosis:

Aortic dissection:

Tx: ascending aorta = surgical emergency; descending: beta-blocker

treatment for myocardial infarctions

Tx: beta-blocker + NTG + aspirin and Plavix + heparin + statins + reperfusion

a 77-year-old Hispanic female with a dull ache in her legs that is worsened with prolonged standing and relieved with rest and elevation of her legs. She has 14 grown children and a past medical history of obesity and hypertension. On physical exam, her bilateral lower legs are edematous with multiple dilated, tortuous superficial veins.

Varicose veins

a 62-year-old male with a 3.5 mm ulcerated area of the right medial malleolus. The wound is inflamed with associated edema. PMH is significant for varicosities.

Venous insufficiency

a 73-year-old female with complaints of heavy, restless legs and nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thromboses after periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles. There are no ulcers. She is scheduled for a duplex ultrasound.

Venous insufficiency

Diagnostics Phlebitis

duplex ultrasonography, venography, D-dimer

gold standard diagnosis for myocarditis

endomyocardial biopsy = gold standard; clinical presentation, cardiovascular MRI; echo = decreased ventricular EF with hypokinesis

Aortic aneurysm treatment

immediate surgical repair beta-blocker

a 72-year-old female who presents to your office for a routine check-up. While she otherwise feels well, it has been a long time since she last received medical care. On exam her you note an apical, rumbling diastolic murmur with a split s1 that occurs following an opening snap. The rumbling is loudest at the start of diastole and is heard best at the left sternal border and apex (mitral area). She has no other physical exam findings and has no other past medical history.

mitral stenosis

A 71-year-old woman with a history of hypertension presents to the office with an ulcer on the anterior aspect of the right leg. She presents to the office because she shopped all day yesterday and has developed significant edema. The skin in the pretibial region appears thin and has excessive brown pigment. What is the most likely diagnosis? A venous insufficiency B arterial insufficiency C expected complication of diabetes mellitus D peripheral neuropathy

venous insufficiency

cause of mitral stenosis

rheumatic heart disease

A retired operating room nurse comes to the clinic complaining of a dull ache in her legs after prolonged standing. She notes her legs feel heavy and she has mild ankle edema when she spends the day shopping. The aching pain and the edema resolve spontaneously if the patient elevates her legs. She denies calf tenderness or dyspnea. Physical examination reveals + 1 ankle edema bilaterally. What is her most likely diagnosis? A deep venous thrombosis B lymphedema C varicose veins D intermittent claudication

varicose veins

ilated, tortuous veins; greater saphenous = MC; flat, reticular veins; telangiectasia; spider veins

varicose veins