Cardiovascular Flashcards
A 70-year-old woman is 2 days post-operative for knee replacement surgery. Her past medical history includes type 2 diabetes and a 40 pack-year history of smoking. She reports feeling suddenly unwell with dizziness, nausea, and vomiting. She denies any chest pain. On examination she is hypotensive and diaphoretic. ECG shows convex ST-segment elevation in leads II, III, and aVF with reciprocal ST segment depression and T-wave inversion in leads I and aVL.
ST-elevated MI
A 78-year-old man presents to his primary care physician complaining of 2 months of progressive shortness of breath on exertion. He first recognises having to catch his breath while gardening and is now unable to walk up the stairs in his house without stopping. Previously he was healthy and active without similar complaints. On physical examination there is a loud systolic murmur at the right upper sternal border radiating to the carotid vessels.
Aortic stenosis
A 62-year-old man is referred for management of atypical multiple myeloma. He has a mild anaemia of 120 g/L (12 g/dL), a urinary protein loss of 2.2 g/day with a urinary immunofixation showing free lambda light chains. However, the bone marrow shows only 5% plasma cells and does not fulfil criteria for multiple myeloma.
Amyloidosis
A 79-year-old man presents with dyspnoea on exertion for 1 year and lower extremity oedema. As part of a cardiac work-up, the echo shows concentric left ventricular hypertrophy. Cardiac catheterisation shows normal coronary arteries and he is referred for further evaluation of non-cardiac dyspnoea.
Amyloidosis
A 76-year-old man presents with progressive symptoms of dyspnoea and increasing peripheral oedema. He denies palpitations. He has a history of CHF from hypertensive heart disease. He reports that he is taking his medications as directed and has had no recent medication or dietary changes.
Atrial flutter
A 60-year-old man with a history of diabetes, hypercholesterolaemia, and heavy smoking for over 20 years presents giving a 3-week history of increasing pain in his left forefoot, which is affecting his ability to walk and is disrupting his sleep. On examination, his left foot is pale, cold, devoid of hair, and his lateral two toes are dusky and discoloured. No foot pulses are palpable and are only just detectable by Doppler probe
Gangrene
A 50-year-old male diabetic smoker presents complaining of leg pain with exertion for 6 months. He notices that he has bilateral calf cramping with walking. He states that it is worse on his right calf than his left and that it goes away when he stops walking. He has noticed that he is able to walk less and less before the onset of symptoms.
PAD (chronic limb ischaemia)
. An 88-year-old woman with a history of dilated cardiomyopathy presents with nausea, light-headedness, and a racing heart. She is taking digoxin and recently her diuretic dosage has been increased. On examination she is alert but weak. Her BP is 108/88 mmHg, and pulse 88 bpm and regular. The lungs are clear. An ECG shows a sustained atrial tachycardia at 180 bpm with 2:1 AV block. Serum potassium is 2.8 mmol/L (2.8 mEq/L)
SVT
An 18-year-old man presents to a clinic reporting 2 episodes of loss of consciousness. The first episode occurred 1 year earlier while playing dodge ball in gym class. He recalls diving to the ground to avoid being hit. On getting up quickly, he noticed feeling lightheaded, sweaty, and nauseated. Apparently, he fell to the ground but does not recall having done so. He later recalls waking up in an accident and emergency (A&E) department. Witnesses reported shaking and clenching of both hands after he had fallen. In the A&E department he was given phenytoin intravenously because of concern that he may have had a seizure. After a negative work-up in the hospital he was prescribed carbamazepine, despite no abnormalities on an electroencephalogram. A year later he had a second episode of loss of consciousness while doing bicep curls. He denies palpitations, tongue biting, or incontinence. He experienced a similar prodrome of warmth and lightheadedness.
Vasovagal syncope
A 10-year-old female Pacific Islander presents with a 2-day history of fever and sore joints. Further questioning reveals that she had a sore throat 3 weeks ago but did not seek any medical help at this time. Her current illness began with fever and a sore and swollen right knee that was very painful. The following day her knee improved but her left elbow became sore and swollen. While in the waiting room her left knee is now also becoming sore and swollen.
Rheumatic fever
A 55-year-old white man presents with weakness, palpitations, and dyspnoea on exertion. On physical examination, his blood pressure is 148/50 mmHg with a bounding pulse and an early diastolic murmur over the left sternal border. He denies any history of drug abuse, rheumatic fever, or connective tissue disorder. The patient is taking hydrochlorothiazide for high blood pressure. Echocardiography reveals a left ventricular ejection fraction (LVEF) of 55%, left ventricular end-diastolic diameter of 70 mm, and end-systolic diameter of 50 mm.
Aortic regurgitation
A 31-year-old woman presents to A&E with a three month history of shortness of breath and palpitations. As a child she had Doxyrubicin chemotherapy to treat bladder cancer. She also notes her cousin died suddenly of a heart attack whilst playing football. On examination, her JVP is raised and a third heart sound can be heard.
Dilated cardiomyopathy
A 73-year-old woman presented for the first time 5 years ago with worsening shortness of breath and lower extremity oedema. On clinical examination, she has a laterally displaced apical impulse, with a loud 3/6 holosystolic murmur at the apex. Jugular veins are distended to the angle of the jaw. Lung examination shows some bibasilar crackles. There is 2-3+ pitting oedema in both lower extremities.
Tricuspid regurgitation
A 43-year-old man with no significant medical history presents with 3 days of progressive fatigue, dyspnoea on exertion and while lying in the supine position, and lower-extremity swelling. He reports having a flu-like illness consisting of fevers, myalgias, fatigue, and respiratory symptoms 2 weeks prior that resolved spontaneously. On examination the patient has an elevated jugular venous pressure, bilateral pulmonary rales, and a heart rate of 104 bpm with an audible left ventricular S3 gallop. He is mildly dyspnoeic at rest but becomes markedly dyspnoeic with minimal exertion.
Myocarditis
A 36-year-old woman presents with a 6-month history of gradually progressive dyspnoea on exertion and fatigue. On physical examination, her vital signs are normal and she appears not to be in any distress. Her lungs are clear to auscultation. Her cardiac examination shows a prominent jugular V wave, an accentuated pulmonic component to the second heart sound (P2), and a high-pitched holosystolic murmur best heard at the left sternal border.
Pulmonary hypertension
A 41-year-old man presents to A&E with increasing shortness of breath, bilateral ankle swelling and ascites. On examination, he has a raised JVP and hepatomegaly. His ECG shows low voltage complexes.
Restrictive cardiomyopathy
A 63-year-old woman with diabetes presents with an episode of retrosternal chest pain and diaphoresis that occurred while walking up stairs earlier that day. Her examination is unremarkable except for blood pressure 156/96 mmHg and abdominal obesity. A recent lipid profile showed triglyceride level 3.8 mmol/L (335 mg/dL), total cholesterol 6.29 mmol/L (243 mg/dL), low-density lipoprotein cholesterol 3.678 mmol/L (142 mg/dL), and high-density lipoprotein cholesterol 0.88 mmol/L (34 mg/dL). Her electrocardiogram shows no acute changes.
Hypertriglyceridaemia
A 65-year-old man with a history of hypertension, diabetes mellitus, and hyperlipidaemia presents to the accident and emergency department with the first episode of rapid palpitations, shortness of breath, and discomfort in his chest. These symptoms started acutely and have been present for 4 hours. Physical examination shows an irregularly irregular radial pulse at rate between 90 and 110 bpm, BP 110/70 mmHg, and respiratory rate of 20 breaths per minute. Heart sounds are irregular, but no S3 or S4 gallop or murmurs are audible. There are no other abnormalities on examination.
Atrial fibrillation
A previously healthy 35-year-old man presents after an all-night binge that included alcohol and cocaine. He is feeling weak and shaky with reduced exercise tolerance. His BP is 110/70 mmHg and heart rate 160 bpm and regular. An ECG shows a narrow complex atrial tachycardia. He is given adenosine 6 mg IV. There is abrupt slowing of the ventricular response rate with no effect on the atrial rate.
SVT
A 45-year-old woman, with a history of type 1 diabetes diagnosed when she was a teenager, presents to the accident and emergency department complaining of abdominal pain, nausea, and shortness of breath that woke her up from sleep.
Unstable angina
A 56-year-old woman with a 6- week history of weight loss, anxiety, and insomnia presents with palpitation and dyspnoea. Her pulse rate is irregular at 140 to 150 bpm. Her BP is 95/55 mmHg. She looks thin, frail, and rather anxious and jittery. Her palms are sweaty and have fine tremors. She has a palpable smooth goitre. Examination of the eyes shows bilateral exophthalmoses.
Atrial fibrillation
A 69-year-old man develops worsening substernal chest pressure after shovelling snow in the morning before work. He tells his wife he feels a squeezing pain that is radiating to his jaw and left shoulder. He appears anxious and his wife calls for an ambulance, as he is distressed and sweating profusely. Past medical history is significant for hypertension and he has been told by his doctor that he has borderline diabetes. On examination in the emergency department he is very anxious and diaphoretic. His heart rate is 112 bpm and blood pressure is 159/93 mmHg. The ECG is significant for ST depression in the anterior leads. Three doses of sublingual glyceryl trinitrate provide little relief.
Non-ST elevated MI
A 56-year-old obese man with poorly controlled type 2 diabetes mellitus presents with symptoms of nausea, vomiting, and worsening abdominal pain after a dinner of steak, chips, and wine. On examination he has diffuse abdominal tenderness, which is most marked in the left upper quadrant. Eruptive xanthomas are noted on his back and forearms. His triglyceride level is 28.3mmol/L (2500mg/dL) and his blood glucose is 20.2mmol/L (364mg/dL). Serum lipase levels are elevated and abdominal ultrasound shows evidence of pancreatitis.
Hypertriglyceridaemia
A 52-year-old woman presents with dyspnoea on exertion, fatigue, and occasional palpitations. She has no prior cardiac history. She denies chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, or lower extremity oedema. On physical examination her jugular venous distension is around 12 cm and her lungs are clear to auscultation. Cardiac examination reveals a slightly displaced apical impulse with a palpable P2. Cardiac auscultation reveals III/VI holosystolic murmur at the apex that radiates to the axilla with diminished S1 and P2 greater than A2.
Mitral regurgitation
A 50-year-old man presents to clinic with a complaint of central chest discomfort of 2 weeks’ duration, occurring after walking for more than 5 minutes or climbing more than 1 flight of stairs. The chest discomfort resolves with rest within several minutes. He is obese, has a history of hypertension, and smokes 10 cigarettes a day. His father died from a myocardial infarction at the age of 54 years. On examination, his blood pressure is 144/92 mmHg with a heart rate of 82 bpm. The remainder of his examination is normal.
Stable angina
A 78-year-old man was diagnosed with left-sided systolic heart failure 14 years ago. He was subsequently found to have atrial fibrillation, and underwent AV node ablation and pacemaker placement 10 years ago that resulted in an improvement in his left ventricular ejection fraction from 35% to 50%. He did extremely well over the years and was extremely active; 3 years ago he completed a 210-mile bike ride across the Netherlands. Four months ago, however, he started developing chest tightness and back tightness when pulling his cart during golfing sessions. In addition, he developed significant dyspnoea with activity and his symptoms have worsened. Now, he says his quality of life is extremely poor. He has problems walking up one flight of stairs where he experiences significant shortness of breath; even walking half a block causes shortness of breath and chest tightness. He has also noticed increased abdominal girth, early satiety, and easy fatigue.
Tricuspid regurgitation
