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80 Cards in this Set
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2 day old neonate w purpuric skin lesions; mother is a recent immigrant from a developing country; pregnancy notable for a flulike illness that was associated with a aculopapulkar rash involving her face and body several weeks after her last menstrual period. Physical examination reveals a lo wbirth weight, catarracts, and harsh crescendo-decresendo systolic murmur most audible at the lef tupper sternal border w radiation to the axilla an dback Laboratory testing demonstrates thrombocytopenia. Dx?
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Cardiac manifestations + blueberry muffin rash + maternal history = congenital rubella syndrome.
Rubella = RNA virus of togaviridiae family and is associated with an 85% risk of congenital defects if acquired in the first 12 weeks of pregnancy. (TORCH infectoins are similar) |
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What heart defect is commonly seen in congenital rubella syndrome (blueberry muffin baby)
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Pulmonary dz (valvular, supravalvular, or pulm artery stenosis)
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What vessel drains the majority of the blood from the cardiac veins back into the chambers of the heart?
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Coronary sinus; lies in the posterior AV groove and opens directly into the right atrium
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60 yo woman with 60 pack year smoking hx; swellin gin both feet over the past 3 months; can't walk as far to the grocery store anymore and has to stop and rest; she awakens at night w difficulty breathing; physical exam is unremarkable and no evidence of hepatosplenomegaly or JVD
Dx? |
Left heart failure (orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion and mild edema)
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What is the most common cause of RHF?
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LHF
Smoking also puts pts at risk for chronic lung dz which can lead to cor pulmonale (RVH) Emphysema is commonly associated with cor pulmonale |
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What are the most likely findings on gross pathology of LHF?
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Hemosiderin laden macrophages in the lung are commonly seen in LHF
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50 yo AA man w dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. PMH = anterior myocardial infarction (MI) 15 months prior. Physical exam reveals mild distress and diaphoresis A holosystolic murmur is audible, particularly at the apex along with a diastolic rumble. The ECG demonstrates sinus tachycardia at a rate of 110/min; left atrial hypertrophy; left ventricular hypertrophy; and deep, broad Q waves in V1, V2, and V3; Echocardiography shows depressed ejection fraction and thinning of the left ventricular walls
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Dilated cardiomyopathy, likely of ischemic etiology. DCM = decreased left ventricular ejection fraction and ventricular chamber w increased diastolic and systolic volumes. It is a major cause of congestive heart failure in young people; men and AA are at increased risk for DCM
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Why might a holosystolic murmur be heard in dilated cardiomyopathy?
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Enlargement of the ventricle dilates the annulus and displaces the papillary muscles (mitrla regurg)
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Pathogenesis of dilated cardiomyopathy after an MI
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Reduced peripheral perfusion (renal) leads to fluid retention in an attempt to increase cardiac out, which results in cardiac remodeling.
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What is acute endocarditis called when it occurs with systemic lupus erythematosus?
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Libman Sacks Endocarditis or "sterile endocarditis;" results from autoimmune damage to cardiac valves
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What characteristic of staphylococcus aureus in acute endocarditis confers resistance to penicillin?
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penicillinase; inactivaes penicillin
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Why is chordae tendinae rupture at risk for acute endocarditis?
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Staphylococcus aureus secretes hyaluronidase, an enzyme that digests connective tissue
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Previously healthy 16 yo boy in Ed w difficulty breathing and substernal chest pain radiating to the neck and shoulder while playing soccer. He denies any drug or cigarette use and had two uncles who died susdenly in their youth. Physical exam is unremarkable except for heart sounds with a sstolic murmur. Dx?
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Hypertrophic cardiomyopathy, sugests by patients age, symptoms, family history of sudden death, and mur. ECG would show deep S wave in V1 and tall R wave in V5 or V6 die tp sogmofocant left ventricular hypertrophy.
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51 yo for physical exam; he was advised to make lifestyle modifications 3 years ago for high bp. High bp has only increased. He has smked one pack a day for 30 years. Dx?
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Hypertension; try lifestyle mod first then pharmacological therapy
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What is the initial pharm therapy for htn
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Thiazide diuretic; inhibits sodium chloride reabsorption in the distal tubule and promotes diuresis; these drugs generally cause fewer adverse effects
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3 yo boy at pediatrician bc mother has had a high fever for the past week. Physical examination reveals bilateral injected conunctivae, palmar erythema, oral mucositis, cervical lymphadenopathy and solar erythma.
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Kawasaki's disease or mucocutaneous lymph node syndrome; commony presents with fever lasting >5 days, erythematous rash, edema in the conjunctivae, lips and mouth (strawberry tongue); palmar and solar erythema; cervical lymphadenitis; and mucositis
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What is the pathophysiology of Kawasaki disease?
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This acute disorder is characterized by necrotizing vasculitis of small and medium sized vessels. it is believed to be of autoimmune or infectious origin.
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45 yo man reports intermittent heart palpitations; auscultation of his chest while sitting reveals a late systolic click associated with a high pitched, late systolic murmur. the systolic click occurs closer to S1 with standing. Normal ECG
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Mitral Valve Prolapse; most common valvular heart disease; common in Marfan's syndrome
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How does standing and squatting affect the timing of the systolic click in mitral valve prolapse?
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MVP, the systolic click represents the sudden tensing of the mitral valve apparatus as the leaflets prolapse into the LA during systole and occurs when the left ventricle reaches a critical volume during ventricular contraction. Standing decreases the end diastolic volume, thereby allowing the CV to be reached earlier. The click therefore is heard closer to S1. In contrast, squatting increases the EDV. The click is thus heard closer to S2
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Pt with chest pain and headaches. No abnormalities on physical exam. Otherwise healthy. Works at munitions plant.
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Nitroglycerin; "monday's disease" because pts become dependent and can exhibit withdrawl symptoms during the weekends
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MOA of nitroglycerin?
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No activates guanlyl cyclase, increases cGMP, which dephosphorylates myosin light chains, inhibits calcium entry, and increases potassium channel activity = vasorelaxation
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What are the major determinants of myocardial oxygen consumption?
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Left ventricular wall tension (determined by preload and afterload), heart rate, contractility
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Useful serum markers in AMI?
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cTN1 (Tropinin 1) i used within the first 4 hours; CK-MB levels peak in 20 hours after the onset of coronary artery occlusion
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What does ST segment elevation indicate?
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AMI; total occlusion of an artery causes ST segment elevation
This is the gold standard to dx AMI soon after onset |
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Pericarditis; diffuse ST segment elevations
This is contrast to ST segment elevation in some MI, which the elvations are limited to ischemic regions. Another classic finding with pericardial effusion is PR segment depression |
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Pulsus Paradoxus
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Decrease in arterial bp by >10 mmHg during inspiration; its a sign of tamponade (compression of heart by fluid in the pericardium)
This compression causes an equilibration of pressure in all four chambers of the heart and a reduction in blood pressure |
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Why would an increase in jugular venous pressure on inspiration be of concern in a pt with pericarditis?
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This is called Kussmaul's sign; indicates constrictive pericarditis, which can lead to compromise of cardiac output
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Causes of serous pericarditis
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Viral infection, SLE,RA, uremia
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Causes of fibrinous pericarditis
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Uremia, MI, RF
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Causes of hemorrhagic pericarditis
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TB, malignancy
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What nerve is associated with the ligamentum arteriosum?
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The recurrent laryngeal nerve, a branch of the left vagus nerve, wraps around the ligamentum arteriosum (embryonically derived from the sixth aortic arch). On the right, the recurrent laryngeal nerve loops around the right subclavian artery (derived from the fourth aortic arch)
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35 yo woman w fatigue and fever; reports ocasional ab pn, headaches, and muscle pn and has lost 7 kg over the past 2 months. On PE, her bp is 154/92 mmHg. Retinal examination reveals cotton wool spots, and skin examination is notable for palpable purpura. Her lab values are as follows:
ESR: 121 ALT: 1700 AST: 1200 |
Polyarteritis nodosa; autoimmine disorder characterized by segmental, transmural inflamation of small and medium sized arteries due to necrotizing immune complexes. Vesels supplying the heart, liver and GI tract often involved
Relevance of ALT and AST = 30% of PAN are associated with hep B infection. |
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Lab test useful for identifying polyarteritis nodosa?
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P-ANCA correlates with dz activity
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What syndrom eshould be suspected if eosinophilia was also present w polyarteritis nodosa presentation
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Churg-Strauss Syndrome; this is a variant of polyarteritis nodosa characterized by eosinophilia and asthma
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33 yo woman from India w profound shortness of breath; progresively unable to walk up stairs wo stopping for breath; paroxymal nocturnal dyspnea; PMH significant for 2 week hospitalization when she was a ten for fever, sore throat, and joint pain. JVD noted, diffuse wheezes and rales at both lun gbases. There is trace edema of her ankles bilaterally. Heart auscultation reveals a low pitched, diastolic murmur with an opening snap, heard best at the apex
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Mitral Stenosis secondary to rheumatic heart disease
Histology: Aschoff bodies and anitschkow myocytes |
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59 yo woman w brief episodes of blurred vision in her right eye when reading the newspaper. On further questioning, she reports she has recently started to have headaches, which worsen at night
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Temporal arteritis; elevated ESR and CRP levels are nonspecific markers associated with this condition; definitive diagnosis biopsy of the temporal artery
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Histopathology of temporal arteritis
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Systemic vasculitis of large and medium sized vessels. One would expect to find mononuclear infiltrates in vessel walls and frequent giant cell formation
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13 month old boy brought tot he pediatrician by his mother, who reports that he hyperentilates an dbecomes blue around the lips and in his fingertips after crying, eating, or any exertion. She has also noticed he tends to squat when he gets these symptoms.
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Tetralogy of Fallot (cyanotic congenital heart disease);
dyspnea on exertion such as feeding or crying. |
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What is the pneumonic to recall anatomic findings in tetralogy of Fallot?
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PROVe
Pulmonary stenosis Right ventricular hypertrophy Overriding aorta (deviation of the origin of the aorta to the right) Ventricular septal defect (CSD) |
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Teratolog of Fallot (cyanotic congenital heat disease); boot shaped heart (due to right ventricular hypertrophy) and aortic arch displaced to the right side of the pt
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Full term baby girl w bluish discoloration of her lips. Her caretakers report that she becomes sweaty with feeding. Prenatal history is notable for lack of prenatal care. Physical exam reveals tachycardia and tachypnea. Her S2 heart sound is single and loud. An early systolic ejection click is audible at the left sternal border. Her hips are maintained in flexion and her extremities are warm and well perfused.
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Truncus Arteriosus; associated with diGeorge's syndrome
TA is the embryologic precursor to the aorta and pulmonary artery. TA is a rare congenital heart dz where a single blood vessel comes out of hte right and left ventricles; this pt likely has low pulmonary flow |
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Pathogenesis of truncus arteriosus?
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Failure of development of the truncoconal septum; if the septum forms but does not spiral, the result is transporition of the great arteries
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22 yo for physical. reports a few episodes of sob, dizziness, and palpitations. These episodes have no clear triggers. Results of physical exam are unremarkable. However, the pts ECG is notable for a shortened PR interval, prolonged QRS complex and a slurred, slow rising onset of the QRS complex (delta wave)
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Wolff-Parkinson White syndrome or prexcitation symdrome
Abnormal band of myocytes creates an accessory conduction pathway, distinct from the AV node, between the atrial and ventricular systems. Since this node is faster than the AV node, the ventricles are excited more quickly. The accessor pathway and shorter refractory period of this pathway presdisposes pts to reentrant tachycardias, atrial fibrillations and atrial flutters. |
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Why is the PR interval shortened in WPW syndrome?
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PR interval = space between atrial and ventricular contraction; WPW accessory pathway which is quicker than AV node decreases this time and thus the PR interval
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Why are class II and IV antiarrythmic drugs not useful in this condition?
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B clockers and calcium channel blockers may not be useful in pts with WPW bc they act by increasing AV node refractoriness and decreasing AV node conduction velocity. They do not slow conduction over accessory pathways and may even shorten the refractory period for accessory pathways;
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Interstitial lung diaseases caused by occupational exposure
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Asbestosis, silicosis, coal worker's pneumoconiosis, berylliosis
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Asbestosis
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Diffuse pulmonary interstitial fibrosis caused by inhaled asbestos fibers; these fibers penetrate bronchioles and lung tissue, where they are surrounded by macrophages and coated by a protein-iron complex (feruginous bodies)
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7 yo in Ed after awakening in middle of night with difficulty breathing. he has a 2 day history of worsening productive cough and wheezing. In ED pt is dyspneic, tachpneic and has a decreased inspiratory to expiratory ratio. Lung exams reveal diffuse ronchi and expiratory wheezes in addition to pulsus paradoxus. He is afebrile with no recent history of fever. This is the pts second visit to the Ed w these symptoms; his first visit was 2 years ago.
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Asthma exacerbation; asthma is a form of obstructive lung disease
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67 yo in Ed w 3 day history of cough and fever and a 1 day history of shaking chills. He has smoked half a pack of cigs per day for 45 yrs; past 9 months man has had an increasingly severe cough that has been productive of clear sputum. Hs cough is now productive of rusty sputum. On physical exam, he is found to have a respiraotry rate of 24/min, and his temp is 100F. An xray of his chest shows lung consolidation
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Community acquired pneuoniae (productive cough, fever, rigors, tachypnea) His risk facotrs include advanced age and smoking history
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most common cause of community acquired pneomina?
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streptococus pneumoniae
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Which vessels supply arterial and venosu branches to the lungs, and what paths do the branches follow to supply each segment?
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Lung alveoli supplied by pulmonary artery and vein
Bronchial tree supplied by bronchial arteries and venous drainage from bronchial veins that feed into the azygos and acessory hemiazygos veins. Pulmonary and bronchial arteries follow the airways into the peripheries. Pulmonary veins course in the septa between adjacent lung segments. |
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A 15 yo girl in Ed in acute respiratory distress and is stabilized w tx. On questioning, she reports an increasingly productive cough over the past few days. Her pulse ox shows 93% oxygen sat on 2L of oxygen, and she foten gasps for air midsentence. Examination shows nostril flaring, subcostal retractions, and clubbing of the fingers. A birth history reveals the patient had a meconium ileus.
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Cystic Fibrosis; loss of function mutation sin the CTFR protein, a chloride channel fond in all exocrine tissues. As a result, secretions in the lung, intestine, pancreas and reproductive tract are extremely viscous. This can obstruct organs, leading to dz complications
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Meconium Ileus
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First sign of cystic fibrosis
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Etiology of respiratory symptoms in a CF patient
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Lungs in a pt with CF are colonized at an early age with various bacteria not normally found int he lung; these pts suffer repeated respiratory infections, leading to increased production of viscous secretions; these secretions lead to increased cough and pulmonary obstruction which can result in acute respiratory distress.
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What vitamin supplements do CF need?
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Fat soluble vitamins A, D, E and K; the thick secretions block the release of pancreatic enzymes, resulting in pancreatic insufficiency
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70 yo woman with a 65 pack year smoking history complains to her physician of worsening dyspnea; now SOB at rest; she admits occasional cough producing thin sputum; exam reveals a thin woman with an increased thoracic AP diameter; the physician notes that his pt breathes through pursed lips, has an increased expiratory phase, and is using her accessory muscles to breath.
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Emphysema
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Why do emphysema pts often exhale through pursed lips?
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Alveolar wall destruction = dilatoin of air spaces; bc of decreased elastic recoil (which increases airway collapsibility causing airway obstruction) pts find it easier to exhale through pursed lips (which maintains a high end expiraotry pressure, stenting the alveoli open); hence the term pink puffers
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Centrilobular emphysema
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Smoking; affects respiratory bronchioles and central alveolar ducts
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Paracinar emphysema
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A1AT deficiency; destruction throughou the acinus
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Pulmonary function test results consistent with COPD
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Dramatically reduced FEV1 and reduced FVC, resulting in a FEC1/FVC ratio of <80%.
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4 yo boy; lethargic; difficulty breathing; saliva drooling out of his mouth; physical exam reveals pt is febrile and his lung exam is notable for a high pitched upper airway wheeze. further questioning of the pts mother reveals the child has not received his immunizations.
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acute epiglottitis likely due to haemophilus influenzae
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What is the main virulence factor of H influenzae (epiglotitis))
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POlysaccharide capsule
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What is a the likely source of h. influenzae epiglottitis?
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H influenzae is normal flora in nasopharynz; organism may spread by direct contact with respiratory secretions or airborne droplet contaminations
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Pleural thickening with an occupational exposure to hazardous material
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Mesothelioma; tumor surrounds and compresses lung; common features include dyspnea, chest pain and pleural effusions
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Greater risks for mesothelioma
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History of asbestos exposure among smokers (pipe fitters, shipyard workers, welders, plumbers and constrution workers)
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Restrictive pattern of pulmonary function tests
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Reduced FEV1 and FVC but a preserved FEV1/FVC ratio
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70 yo man with history o flaryngeal cancer in ED for SOB; hx of 3 days orthopnea and noctural dyspnea; a decubitis chest film shows layeriny of fluid
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pleural effusion;
Transudative pleural effusions: increased hydrostatic pressure in pleural capillaryes (CHF) Exudative peural effusions: Changes in the permeability of the pleural surface (inflammatory or neoplastic) - these have a high protein content |
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18 yo man w 3 wk hx of worsening dry and nonproductive cough; throbbing headache along with a mild fever and complains of malaise and sore throat. Tx with penicillin has not relieved his symptoms. His 16 yo bro developed similar symptoms
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Atypical pneumoniae (walking pneumonia) due to myoplasma pneominae; this organism is the smlleast free living bacterium - has no cell wall and its membrane is the only bacterial membrane containing cholesterol
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62 yo woman in eD with acute onset of shortness of breath; stabbing pleuritic right sided chest pain; the woman had a stroke 3 months ago but is otherwise health. BP 90/60, HR = 110/min, RR = 40/min, sat = 77% on room air. Physical exam reveals JVD, and unremarkable cardio exam. The womans lungs are clear bilaterally with decreased breath sounds in the right middle lobes. She has mild cyanosis in the distal extremities with no clubbing.
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PUlmonary embolism
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Lines of Zahn
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Characteristic of of thrombotic event
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Gold standard for dx PE
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Pulmonary angiography; an also check plasma D dimer levels
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40 yo womanw ith history of interstitial lung disease at ED w cc of fatigue and weakness.
lab values: pH: 7.32 PC02: 91 mmHg |
The patient has respiratory acidosis (pH < 7.4, PC02 > 400 mmHg) with a compensatory metabolic alkalosis
the interstitial lung dz can chronically impair gas exchange |
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35 yo black man with progressive dyspnea on exertion; no history of CHF or asthma or TB; normal CK-MB and troponin; x ray of chest shows bilateral hilary lymphadenopathy and evidence of interstitial lung disease. A thoracoscopic lung biopsy reveals the presence of several small, noncaseating granulomas in both lungs.
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Sarcoidosis; noncaseating granulomas are collections of macrophages in the absence of caseation (as you'd see in TB or histo); these granulomas frequently contain multinucleated giant cells and are accompanied by alveolitis
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56 yo man with 20 lb weight loss over the past 8 weeks. His voice is hoarse and he is unable to keep up with his work as a construction worker. The pt has a 30 pack year cig smoking history. Physician orders PA radiograph which shows a central, hilar lung mass
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Hilar lung mass + history of weight loss strongly suggests small cell lung carcinoma
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Why does a hilar mass (scc) cause hoarseness?
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recurrent laryngeal nerve compression, phrenic nerve palsy could also result in dyspnea, dysphagia from esophageal compression and stridor due to tracheal compression
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55 yo man in Ed cc sudden right sided chest pn followed by dififulty breathing; man has severe emphysema due to ane xtensive history of tobacco use; on physical exam the patient is tachypneic and tachycardic; his breath sounds are diminished at the right apex and his chest wall is hyperresonant to percussion. No tactile fremitus noted. Arterial blood gas analyses demonstrates a partial pressure of oygen of 60 mmHg and a partial pressure of carbon dioxide of 50 mmHg.
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Spontaneous pneumothorax;
Primary spontaneous pneumothorax = absence of lung dz Secondary pneumothorax = chronic lung dz |
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Patohphysiology of secondary spontaneous pneumothorax
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Spontaeous pneumothorax likely caused by a rupture of a subpleural bleb, which allows air to escape into the pleural cavity.
Tension pneumothorax = one way valve allows air to gradually accumulate with each inspiration and air cannot be expelled during exhalation |
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tension pneumothorax radiograph
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tracheal and medistinal deviation AWAY from pneumothorax
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nontension pneumothorax
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trachea and mediastinum deviation TOWARDS the side of collapsed lung
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Horners Syndrome
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Pancoast tumor at apex of the lung can compress the stellate ganglion
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