Cardiology Exam 3 Review

Ventricular interdependence in constrictive pericarditis refers to which of the following?

• Dependence of amount of blood flow into each ventricle during a typical breathing cycle

• Shifting of interventricular septum towards the left ventricle during expiration

• Greater increase in blood flow into the left ventricle during inspiration compared to that for the right ventricle

• Permanent shifting of the interventricular septum towards the left ventricle due to thickened pericardium

• Inadequate blood flow into the ventricles during inspiration

Which of the following findings should be utilized in the diagnosis of constrictive pericarditis and its differentiation from restrictive cardiomyopathy?

• Doppler echocardiogram – ventricular interdependence

• Endomyocardial biopsy – absence of amyloidosis or other infiltrative disease

• CT/MRI imaging – thickened pericardium

• Chest radiography – pericardial calcification

• All of the above

Pericardial stripping is a surgical procedure where the entire pericardium is peeled away from the heart.  Which of the following pathologies may require this type of intervention?

• Primary cardiomyopathy

• Infective endocarditis

• Restrictive cardiomyopathy

• Constrictive pericarditis

• Hypertrophic cardiomyopathy

Which of the following key signs is found in acute pericarditis?

• Chest pain

• Audible pericardial friction rub

• Dyspnea on exertion

• ST segment changes on ECG

• Fever

Beck's triad is a collection of three medical signs associated with acute cardiac tamponade, an emergency condition wherein fluid accumulates around the heart and impairs its ability to pump blood.   Which of the following Beck’s triad sign are consistent with diagnosis of cardiac tamponade?

• Jugular vein distension, exaggerated heart sounds, hypertension

• Hepatojugular reflux, pericardial friction rub, T-wave depression

• Hypotension, jugular vein distension, muffled heart sounds

• Hypotension, tachycardia, tachypnea

• Dullness to percussion beneath the angle of left scapula, accumulation of pericardial fluid, muffled heart sounds

Which of the following tests is useful in late diagnosis of myocardial infarction?

• Troponin test

• Prothrombin test

• Creatine kinase (CK-MB) test

• Myoglobin (Mb) test

• Ischemia-modified serum albumin (IMA) test

A 45-year-old man is admitted to the hospital for symptoms of severe congestive heart failure, including dyspnea on exertion, swelling in the legs, and difficulty lying down flat in bed.  Which of the following would be most consistent with chronic alcohol consumption?

• Restrictive cardiomyopathy

• Valvular stenosis

• Pericardial effusion

• Dilated cardiomyopathy

• Acute coronary syndrome

A 39-year-old man arrives at the emergency department with 2 weeks of fever, night sweats, and arthralgias.  The physical examination discloses a heart murmur, lower extremity petechiae, splinter hemorrhages on his nail beds, and small nonpainful hemorrhagic patches on his palms and soles of his feet.  What is the most likely diagnosis in this patient?

• Acute rheumatic fever

• Infective endocarditis

• Marfan's syndrome

• Primary cardiomyopathy

• Secondary cardiomyopathy

A 55-year old male presents with complaints of chest pain and dyspnea of several days duration.  He further describes his chest pain as worst while lying down and somewhat better with sitting up.  His physical exam is unremarkable, except for a pericardial friction rub and an elevated temperature of 101.2°F.  What is the most likely etiology for this clinical presentation?

• Congestive heart failure

• Endocarditis

• Pericarditis

• Pleural effusion

• Coronary artery disease

A 28 y/o male comes to the emergency room complaining of 6 days of fever with shaking chills. Over the past two days he has also developed a productive cough with greenish sputum. He has also noticed that occasionally the sputum is blood streaked. He reports to having no dyspnea, but sometimes he does experience chest pain upon deep inspiration. He does not have headaches, abdominal pain, urinary symptoms. No nausea, vomiting, or diarrhea. No significant past medical history. He does smoke. He drinks several beers daily. Denies IV drug use. Upon physical examination, his oral temperature was recorded at 102.5 degrees F. His heart rate was 109 bpm and his BP was 128/76. His respiration count was 23 per minute. He was alert awake and oriented. He has no oral lesions and his fundoscopic exam was normal. He has no JVD and his heart was appreciated with tachycardia and had a harsh holosystolic murmur heard at the left lower sternal border that increased with inspiration. His lung exam exhibited inspiratory rales bilaterally. On both forearms, he has linear streaks of induration, hyperpigmentation, with small nodules overlaying the superficial veins.  The labs ran were appreciative of the following: WBC: 17,500/mm3 84% polymorphonuclear cells Platelets: 189,000 Liver function: normal Urinalysis: normal CXR: showed multiple peripheral ill-defined nodules with some cavitations What kind of valvular problem does this patient elicit?

• Mitral valve regurgitation

• Mitral valve prolapse

• Tricuspid valve regurgitation

• Tricuspid valve prolapse

• Aortic valve regurgitation

A 28 y/o male comes to the emergency room complaining of 6 days of fever with shaking chills. Over the past two days he has also developed a productive cough with greenish sputum. He has also noticed that occasionally the sputum is blood streaked. He reports to having no dyspnea, but sometimes he does experience chest pain upon deep inspiration. He does not have headaches, abdominal pain, urinary symptoms. No nausea, vomiting, or diarrhea. No significant past medical history. He does smoke. He drinks several beers daily. Denies IV drug use.  Upon physical examination, his oral temperature was recorded at 102.5 degrees F. His heart rate was 109 bpm and his BP was 128/76. His respiration count was 23 per minute. He was alert awake and oriented. He has no oral lesions and his fundoscopic exam was normal. He has no JVD and his heart was appreciated with tachycardia and had a harsh holosystolic murmur heard at the left lower sternal border that increased with inspiration. His lung exam exhibited inspiratory rales bilaterally. On both forearms, he has linear streaks of induration, hyperpigmentation, with small nodules overlaying the superficial veins.  The labs ran were appreciative of the following: WBC: 17,500/mm3 84% polymorphonuclear cells Platelets: 189,000 Liver function: normal Urinalysis: normal CXR: showed multiple peripheral ill-defined nodules with some cavitations  What is your differential diagnosis?

A 28 y/o male comes to the emergency room complaining of 6 days of fever with shaking chills. Over the past two days he has also developed a productive cough with greenish sputum. He has also noticed that occasionally the sputum is blood streaked. He reports to having no dyspnea, but sometimes he does experience chest pain upon deep inspiration. He does not have headaches, abdominal pain, urinary symptoms. No nausea, vomiting, or diarrhea. No significant past medical history. He does smoke. He drinks several beers daily. Denies IV drug use.  Upon physical examination, his oral temperature was recorded at 102.5 degrees F. His heart rate was 109 bpm and his BP was 128/76. His respiration count was 23 per minute. He was alert awake and oriented. He has no oral lesions and his fundoscopic exam was normal. He has no JVD and his heart was appreciated with tachycardia and had a harsh holosystolic murmur heard at the left lower sternal border that increased with inspiration. His lung exam exhibited inspiratory rales bilaterally. On both forearms, he has linear streaks of induration, hyperpigmentation, with small nodules overlaying the superficial veins.  The labs ran were appreciative of the following: WBC: 17,500/mm3 84% polymorphonuclear cells Platelets: 189,000 Liver function: normal Urinalysis: normal CXR: showed multiple peripheral ill-defined nodules with some cavitations  How would you proceed? (Check all that apply)

• Run a sputum culture

• Treat immediately with Ampicillin

• Treat immediately with Gentamicin

• Run a blood culture at least twice from different sites at different times

• Run a blood culture when the patient is spiking a fever

A 28 y/o male comes to the emergency room complaining of 6 days of fever with shaking chills. Over the past two days he has also developed a productive cough with greenish sputum. He has also noticed that occasionally the sputum is blood streaked. He reports to having no dyspnea, but sometimes he does experience chest pain upon deep inspiration. He does not have headaches, abdominal pain, urinary symptoms. No nausea, vomiting, or diarrhea. No significant past medical history. He does smoke. He drinks several beers daily. Denies IV drug use. Upon physical examination, his oral temperature was recorded at 102.5 degrees F. His heart rate was 109 bpm and his BP was 128/76. His respiration count was 23 per minute. He was alert awake and oriented. He has no oral lesions and his fundoscopic exam was normal. He has no JVD and his heart was appreciated with tachycardia and had a harsh holosystolic murmur heard at the left lower sternal border that increased with inspiration. His lung exam exhibited inspiratory rales bilaterally. On both forearms, he has linear streaks of induration, hyperpigmentation, with small nodules overlaying the superficial veins.  The labs ran were appreciative of the following: WBC: 17,500/mm3 84% polymorphonuclear cells Platelets: 189,000 Liver function: normal Urinalysis: normal CXR: showed multiple peripheral ill-defined nodules with some cavitations  This patient is allergic to Penicillin. What medications can you use to treat this patient? (choose all applicable options)

• Cephalexin

• Amoxicillin

• Clindamycin

• Apmicillin

• Azithromycin

A 28 y/o male comes to the emergency room complaining of 6 days of fever with shaking chills. Over the past two days he has also developed a productive cough with greenish sputum. He has also noticed that occasionally the sputum is blood streaked. He reports to having no dyspnea, but sometimes he does experience chest pain upon deep inspiration. He does not have headaches, abdominal pain, urinary symptoms. No nausea, vomiting, or diarrhea. No significant past medical history. He does smoke. He drinks several beers daily. Denies IV drug use. Upon physical examination, his oral temperature was recorded at 102.5 degrees F. His heart rate was 109 bpm and his BP was 128/76. His respiration count was 23 per minute. He was alert awake and oriented. He has no oral lesions and his fundoscopic exam was normal. He has no JVD and his heart was appreciated with tachycardia and had a harsh holosystolic murmur heard at the left lower sternal border that increased with inspiration. His lung exam exhibited inspiratory rales bilaterally. On both forearms, he has linear streaks of induration, hyperpigmentation, with small nodules overlaying the superficial veins.  The labs ran were appreciative of the following: WBC: 17,500/mm3 84% polymorphonuclear cells Platelets: 189,000 Liver function: normal Urinalysis: normal CXR: showed multiple peripheral ill-defined nodules with some cavitations  This patient is allergic to Penicillin and is unable to take oral medications. What medications would you use to treat this patient?

• Ampicillin

• Clindamycin

• Cefazolin

• Clarithromycin

A 68 y/o male is hospitalized with Streptococcus bovis. He has endocarditis involving the mitral valve. He recovers completely with the appropriate therapy. What's your next step?

• Suggest good dental hygiene plus proper dental fitting of false teeth to prevent reinfection and damage of the mitral valve

• Repeat echo in six weeks to ensure that the vegetations have resolved

• Do a colonoscopy to look for mucosal lesions

• Mitral valve replacement to prevent systemic embolic events

A 24 y/o IVDA is admitted with 4 weeks of fever. He has 3 blood cultures that are positive for candidiasis. He suddenly develops a cold blue toe. What's your next step?

• Repeat the echo to see if the large aortic vegetation previously seen has embolized

• Cardiovascular surgery consult for aortic valve replacement

• Aortic angiography to evaluate if that is where the mycotic infection is and if it's a mycotic aneurysm

• Switch him from Fluconazole to Amphoterecin B

Which of the following patients needs antimicrobial prophylaxis before dental surgery?

• Patient with Atrial Septal Defect

• Patient with Mitral Valve Prolapse without Mitral Regurgitation

• Patient with previous Coronary Artery Bypass Graft

• Patient with previous Infectious Endocarditis

A 35 y/o woman is noted to have a positive Kussmaul sign. Which of the following conditions does she most likely have?

• Constrictive pericarditis

• Cardiac tamponade

• Dilated cardiomyopathy

• Diabetic ketoacidosis

Which of the following is the most sensitive finding in patients with cardiac tamponade?

• Disappearance of radial pulse during inspiration

• Drop in systolic blood pressure more than 10 mm Hg during inspiration

• Rise in heart rate more than 20 bpm during inspiration

• Distant heart sounds

While awaiting pericardiocentesis, immediate supportive care of a patient with cardiac tamponade should include which of the following?

• Diuresis with furosemide

• Intravenous fluids

• Nitrates to lower venous congestion

• Morphine to relieve dyspnea

Which of the following is most likely to cause restrictive cardiomyopathy?

• Endomyocardial fibrosis

• Viral myocarditis

• Beriberi (thiamine deficiency)

• Doxorubicin therapy

19 y/o male comes to the emergency room because of a MVA in which he was the driver and sustained blunt trauma to the anterior trunk from striking the steering wheel and dash board. The patient is alert, short of breath, hypotensive, and complains of acute chest pain. On auscultation, you hear muffled heart sounds. What's his diagnosis?

A 39 y/o male presents to the ER with a one week history of severe chest pain. He states that the pain seems to worsen when he lays down. He describes the pain as radiating to the back and it also worsens when he takes a deep breath. His blood pressure 124/84, respirations 18, temperature 101 F, pulse 74. On auscultation of the chest, you cannot distinguish between S1 and S2, but you hear a grunting sound. Which of the following would be your first step in managing this patient?

• Pericardial window

• Beta blocker

• Rest and NSAIDS

• Cortisol

A 46 y/o male who is recovering from acute MI complains of sharp pain behind the sternum which is made worse by coughing. He feels relief with sitting forward. On examination, a scratchy superficial sound is heard at the left sternal edge. His heart sounds are muffled. He has some ascites and slightly raised JVP? Which of the following would you most likely see on his EKG?

• Sinus tachycardia

• ST changes

• Increased PR intervals

• Atrial fibrillation

• High voltage

A 33 y/o male develops a low grade fever. A week later he develops dyspnea and palpitations. He dies suddenly and unexpectedly. During autopsy, the medical examiner finds a diffusely enlarged floppy heart with no focal lesions. Coronary arteries show minimal atherosclerotic lesions with no narrowing. The most likely etiology for these findings is?

• Cocaine overdose

• Viral myocarditis

• Systemic lupus

• Acute rheumatic fever

• Endomyocardial fibrosis

In tuberculous pericarditis, the TB skin test is usually negative.

• True

• False

Beck's triad includes a decline in systemic arterial pressure, an elevation in systemic arterial pressure, and a small quiet heart.

• True

• False