Cardiology Exam 3 Review

The patient's symptoms of chest pain that worsens while lying down and improves with sitting up, along with the presence of a pericardial friction rub and an elevated temperature, are indicative of pericarditis. Pericarditis is inflammation of the pericardium, the sac-like membrane surrounding the heart. It commonly presents with chest pain that is sharp and pleuritic in nature, worsened by lying down and improved by sitting up. The pericardial friction rub heard on physical examination is a classic finding in pericarditis.

Patients with previous Infectious Endocarditis need antimicrobial prophylaxis before dental surgery. Infectious Endocarditis is an infection of the inner lining of the heart chambers and valves. Dental procedures can introduce bacteria into the bloodstream, which can then travel to the heart and cause an infection in individuals with a history of Infectious Endocarditis. Therefore, to prevent this complication, these patients should receive antimicrobial prophylaxis before dental surgery. Atrial Septal Defect, Mitral Valve Prolapse without Mitral Regurgitation, and previous Coronary Artery Bypass Graft do not necessarily require antimicrobial prophylaxis before dental surgery.

The signs of hypotension, jugular vein distension, and muffled heart sounds are consistent with the diagnosis of cardiac tamponade. Hypotension indicates low blood pressure, which can be caused by the impaired ability of the heart to pump blood due to fluid accumulation. Jugular vein distension occurs when there is increased pressure in the veins leading to the heart, which can be a result of fluid accumulation. Muffled heart sounds suggest that the fluid around the heart is interfering with its normal functioning and ability to produce clear sounds. Therefore, these signs together indicate the presence of cardiac tamponade.

Constrictive pericarditis is the correct answer because it is a condition characterized by inflammation and scarring of the pericardium, which leads to the thickening and stiffening of the pericardial sac. This can result in impaired filling of the heart and decreased cardiac output. Pericardial stripping may be necessary in severe cases of constrictive pericarditis to remove the thickened and scarred pericardium, allowing for improved heart function. Primary cardiomyopathy, infective endocarditis, restrictive cardiomyopathy, and hypertrophic cardiomyopathy are not typically treated with pericardial stripping.

Chronic alcohol consumption can lead to dilated cardiomyopathy. This condition is characterized by the enlargement of the heart chambers, resulting in decreased pumping ability and heart failure symptoms such as dyspnea on exertion, leg swelling, and difficulty lying flat in bed. Restrictive cardiomyopathy, valvular stenosis, pericardial effusion, and acute coronary syndrome are not directly associated with chronic alcohol consumption.

The most likely diagnosis in this patient is infective endocarditis. The presence of fever, night sweats, arthralgias, heart murmur, lower extremity petechiae, splinter hemorrhages, and hemorrhagic patches on the palms and soles are all consistent with the clinical manifestations of infective endocarditis. Acute rheumatic fever is unlikely as it typically presents with migratory polyarthritis and carditis, which are not described in this patient. Marfan's syndrome is not associated with the specific findings mentioned. Primary and secondary cardiomyopathies do not typically present with the same constellation of symptoms and physical examination findings as seen in this patient.

The patient's presentation of acute chest pain, muffled heart sounds, and hypotension following blunt trauma to the anterior trunk is consistent with cardiac tamponade. Cardiac tamponade occurs when fluid accumulates in the pericardial sac, causing compression of the heart and impaired cardiac function. This can result from trauma, such as in this case, leading to rupture of blood vessels and subsequent accumulation of blood in the pericardial sac. The muffled heart sounds are due to the fluid surrounding the heart, impairing its ability to transmit sound. Prompt intervention, such as pericardiocentesis, is necessary to relieve the pressure on the heart and restore cardiac function.

Beck's triad actually includes three specific signs that are indicative of cardiac tamponade, which is a medical emergency. These signs are low arterial blood pressure, distended neck veins, and muffled or distant heart sounds. It does not include an elevation in systemic arterial pressure. Therefore, the correct answer is false.

All of the above findings should be utilized in the diagnosis of constrictive pericarditis and its differentiation from restrictive cardiomyopathy. Doppler echocardiogram can show ventricular interdependence, which is a characteristic feature of constrictive pericarditis. Endomyocardial biopsy can help rule out amyloidosis or other infiltrative diseases that can present with similar symptoms. CT/MRI imaging can show thickened pericardium, another characteristic finding in constrictive pericarditis. Chest radiography can reveal pericardial calcification, which is often seen in chronic constrictive pericarditis. Therefore, all of these findings are important in making a definitive diagnosis and differentiating it from restrictive cardiomyopathy.

In acute pericarditis, an audible pericardial friction rub is a key sign. This is a scratching or grating sound heard on auscultation of the heart, caused by the inflamed pericardial layers rubbing against each other. Chest pain is also commonly present in acute pericarditis, along with fever. Dyspnea on exertion can occur due to the inflammation and fluid accumulation in the pericardial sac. ST segment changes on ECG may also be seen in acute pericarditis, but the most specific and characteristic sign is the audible pericardial friction rub.

A drop in systolic blood pressure more than 10 mm Hg during inspiration is the most sensitive finding in patients with cardiac tamponade. Cardiac tamponade is a condition where fluid accumulates in the pericardial sac, compressing the heart and impairing its ability to fill and pump blood effectively. During inspiration, the negative intrathoracic pressure causes an increase in venous return to the heart. In patients with cardiac tamponade, this increased venous return further compromises cardiac output, leading to a significant drop in systolic blood pressure. This finding is considered the most sensitive because it directly reflects the hemodynamic consequences of cardiac tamponade.

The patient is presenting with symptoms of pericarditis, which is inflammation of the pericardium, the sac surrounding the heart. The sharp pain behind the sternum, worsened by coughing and relieved by sitting forward, is a classic symptom of pericarditis. The scratchy superficial sound heard at the left sternal edge is known as a pericardial friction rub. The muffled heart sounds and the presence of ascites and raised JVP suggest pericardial effusion, which is fluid accumulation in the pericardial sac. In pericarditis, ST changes are commonly seen on the EKG, such as ST segment elevation or depression. Therefore, the most likely finding on the patient's EKG would be ST changes.

Endomyocardial fibrosis is the most likely cause of restrictive cardiomyopathy. This condition involves the thickening and hardening of the endocardium, the inner lining of the heart chambers. This leads to a restricted filling of the ventricles, impairing their ability to relax and fill with blood properly. Other options such as viral myocarditis, beriberi, and doxorubicin therapy can cause different types of cardiomyopathy but are less commonly associated with restrictive cardiomyopathy.

In tuberculous pericarditis, the TB skin test is usually positive. This is because tuberculous pericarditis is caused by the bacteria Mycobacterium tuberculosis, which can trigger an immune response in the body. The TB skin test, also known as the Mantoux test, involves injecting a small amount of purified protein derivative (PPD) from the bacteria under the skin. If a person has been exposed to TB, their immune system will react to the PPD, causing a red bump or swelling at the injection site. Therefore, in tuberculous pericarditis, the TB skin test is typically positive, indicating exposure to the bacteria.

The patient's symptoms, including severe chest pain that worsens when lying down, radiates to the back, and worsens with deep breaths, along with the auscultation finding of not being able to distinguish S1 and S2 but hearing a grunting sound, are suggestive of pericarditis. Rest and NSAIDs are the initial management options for pericarditis, as they help reduce inflammation and relieve pain. Therefore, the correct first step in managing this patient would be rest and NSAIDs.

The patient's presentation is consistent with infective endocarditis. The presence of fever with shaking chills, productive cough with greenish sputum, and blood streaked sputum suggest an infectious process. The patient also has a harsh holosystolic murmur heard at the left lower sternal border that increases with inspiration, which is indicative of a valvular abnormality. The linear streaks of induration, hyperpigmentation, and small nodules overlaying the superficial veins on the forearms are suggestive of Janeway lesions, which are seen in infective endocarditis. The CXR findings of multiple peripheral ill-defined nodules with cavitations further support the diagnosis of infective endocarditis with septic embolus. The elevated WBC count and presence of polymorphonuclear cells indicate an inflammatory response.

A positive Kussmaul sign refers to an abnormal increase in jugular venous pressure (JVP) during inspiration. This is commonly seen in constrictive pericarditis, a condition characterized by the thickening and stiffening of the pericardium, the sac that surrounds the heart. In constrictive pericarditis, the pericardium restricts the heart's ability to expand during diastole, leading to increased JVP. Cardiac tamponade, dilated cardiomyopathy, and diabetic ketoacidosis are not typically associated with a positive Kussmaul sign.

The most likely etiology for the findings described in the question is viral myocarditis. This is indicated by the patient's symptoms of low-grade fever, dyspnea, and palpitations, which are commonly associated with viral myocarditis. The autopsy findings of a diffusely enlarged floppy heart with no focal lesions also support this diagnosis. Additionally, the absence of significant atherosclerotic lesions and narrowing in the coronary arteries suggests that atherosclerosis is not the cause of the patient's symptoms and death.

Based on the patient's symptoms and physical examination findings, as well as the laboratory and imaging results, the patient is likely experiencing tricuspid valve regurgitation. The patient has a history of fever, productive cough with greenish sputum, and blood streaked sputum, which are suggestive of a respiratory infection. The presence of a harsh holosystolic murmur heard at the left lower sternal border that increases with inspiration indicates tricuspid valve involvement. The inspiratory rales bilaterally suggest pulmonary involvement. The CXR findings of multiple peripheral ill-defined nodules with some cavitations further support the diagnosis of tricuspid valve regurgitation.

The patient's presentation of a sudden cold blue toe suggests a possible embolization from the large aortic vegetation. Aortic angiography would be the next step to evaluate if the mycotic infection has caused a mycotic aneurysm and to determine the location of the infection. This would help guide further management decisions, such as the need for surgical intervention or a change in antifungal therapy. Switching the antifungal medication alone would not address the underlying cause of the embolization.

Intravenous fluids should be included in the immediate supportive care of a patient with cardiac tamponade. Cardiac tamponade is a condition where fluid accumulates in the pericardial sac, putting pressure on the heart and impairing its ability to pump blood effectively. Intravenous fluids help to increase the volume of circulating blood, which can improve cardiac output and blood pressure. This is important in managing cardiac tamponade as it helps to maintain organ perfusion and prevent further deterioration. Diuresis with furosemide, nitrates, and morphine may be used in certain cases, but intravenous fluids are the most essential initial intervention.

The Creatine kinase (CK-MB) test is useful in the late diagnosis of myocardial infarction. CK-MB is an enzyme found predominantly in the heart muscle, and its levels in the blood rise within a few hours after a heart attack. By measuring CK-MB levels, doctors can determine if there has been damage to the heart muscle and confirm the diagnosis of myocardial infarction. Other tests like the Troponin test, Prothrombin test, Myoglobin test, and Ischemia-modified serum albumin (IMA) test may also be used in the diagnosis of myocardial infarction, but the CK-MB test specifically detects heart muscle damage.

Based on the patient's symptoms and physical examination findings, as well as the CXR results, the most likely diagnosis is community-acquired pneumonia with lung abscess formation. The patient's symptoms of fever, productive cough with greenish sputum, and blood streaked sputum, along with the physical examination findings of tachycardia, harsh holosystolic murmur, and inspiratory rales, are consistent with this diagnosis. The CXR findings of multiple peripheral ill-defined nodules with cavitations further support this diagnosis. Cefazolin is an appropriate choice for the treatment of community-acquired pneumonia, especially in patients who are allergic to penicillin.

Ventricular interdependence in constrictive pericarditis refers to the dependence of the amount of blood flow into each ventricle during a typical breathing cycle. In constrictive pericarditis, the thickened pericardium restricts the expansion of the ventricles during inspiration, leading to decreased filling of both ventricles. This causes an imbalance in the blood flow between the left and right ventricles. During inspiration, the increased blood flow into the left ventricle is dependent on the decreased blood flow into the right ventricle. This interdependence is a characteristic feature of constrictive pericarditis.

Streptococcus bovis is known to contribute to colon carcinoma. You want to look at the colon!

Based on the patient's symptoms and physical examination findings, as well as the CXR results, it is likely that the patient has community-acquired pneumonia with lung abscesses. The presence of blood streaked sputum and the harsh holosystolic murmur suggest the possibility of septic emboli from the lung abscesses. Given that the patient is allergic to Penicillin, Cephalexin, Clindamycin, and Azithromycin can be used as alternative antibiotics for the treatment of this patient's condition.

After hearing a recording of our cardiology lecture, Santana said specifically: "You want to wait until after you get your lab results back to treat the patient with medication". His reasoning was that you don't know if it's a fungal infection or bacterial and if it's bacterial... you dont know what kind of bacteria it is.....