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ELM2 - integrated cases > case 7 - fainting > Flashcards

case 7 - fainting Flashcards

1
Q

What is the area of auscultation for listening to the aortic valve?

A

2nd intercostal space, right sternal border

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2
Q

What is the area of auscultation for listening to the pulmonary valve?

A

2nd intercostal space, left sternal border

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3
Q

What is the area of auscultation for listening to the tricuspid valve?

A

4th to 5th intercostal space, left sternal border

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4
Q

What is the area of auscultation for listening to the mitral valve?

A

5th intercostal space, towards apex, roughly around the midclavicular line

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5
Q

Which valves is the S1 heart sound associated with?

A

Tricuspid & mitral valves (closing)

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6
Q

Which valves is the S2 heart sound associated with?

A

Aortic & pulmonary valves (closing)

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7
Q

What part of the cardiac cycle does the S1 heart sound mark?

A

Beginning of systole

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8
Q

What part of the cardiac cycle does the S2 heart sound mark?

A

End of systole

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9
Q

What technique is used to differentiate between a diastolic and systolic murmur?

A

Simultaneous palpation of the carotid pulse

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10
Q

Which heart sound are diastolic murmurs associated with?

A

S1

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11
Q

Which heart sound are systolic murmurs associated with?

A

S2 heart sound

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12
Q

Which phase of the carotid pulse do diastolic murmurs coincide with?

A

Between pulses of the artery

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13
Q

Which phase of the carotid pulse do systolic murmurs coincide with?

A

During pulses of the artery.

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14
Q

What is heart valve stenosis?

A

When a valve is narrow/constricted, reducing the amount of blood that can flow through to the following heart chamber.

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15
Q

What is heart valve regurgitation?

A

When a valve does not close properly, allowing blood to leak back to the previous heart chamber

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16
Q

Is stenosis of the aortic valve a systolic or diastolic murmur?

A

Systolic

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17
Q

Is regurgitation of the aortic valve a systolic or diastolic murmur?

A

Diastolic

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18
Q

Is stenosis of the pulmonary valve a systolic or diastolic murmur?

A

Systolic

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19
Q

Is regurgitation of the pulmonary valve a systolic or diastolic murmur?

A

Diastolic

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20
Q

Is stenosis of the mitral valve a systolic or diastolic murmur?

A

Diastolic

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21
Q

Is regurgitation of the mitral valve a systolic or diastolic murmur?

A

Systolic

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22
Q

Is stenosis of the tricuspid valve a systolic or diastolic murmur?

A

Diastolic

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23
Q

Is regurgitation of the tricuspid valve a systolic or diastolic murmur?

A

Systolic

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24
Q

What does the murmur of aortic stenosis sound like?

A

Systolic, harsh murmur followed by a distinct sound.

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25
Q

What changes occur to the apex beat in aortic stenosis, and why?

A

Forceful apex beat, because the left ventricle has to beat harder to pump blood through the narrowed aortic valve

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26
Q

Why does aortic stenosis cause hypertension?

A

Systolic blood pressure in the aorta can be increased due to ventricular hypertrophy and a forceful apex beat.

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27
Q

Why does the left ventricle become hypertrophied in aortic stenosis?

A

The left ventricle must work harder to force blood through the narrowed aortic valve, so the myocardium hypertrophies in an attempt to increase the force of contraction.

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28
Q

Why does the left atrium sometimes become enlarged when there is aortic stenosis?

A

Because the upstream pressure increases as a result of increased left ventricular pressure

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29
Q

Why can aortic stenosis cause aortic dilation or aneurysm?

A

Blood leaving the aortic valve is turbulent and high pressure, so can put stress on the wall of the aorta.

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30
Q

What are the clinical features of aortic stenosis?

A

Forceful apex beat, left ventricular hypertrophy, hypertension, left atrial enlargement, aortic dilation/aneurysm, peripheral cyanosis, systolic murmur

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31
Q

What are the symptoms of aortic stenosis?

A

Fainting, peripheral cyanosis, chest pain, dizziness/pre-syncope, breathlessness

32
Q

Why can aortic stenosis cause chest pain?

A

The narrowed valve can cause weak cardiac output so poor supply to the coronary arteries. In addition, the hypertrophied left ventricle has higher oxygen demands, which may be difficult to meet.

33
Q

What are the key investigations for diagnosis of aortic stenosis?

A

Echocardiography, cardiac angiography, ECG, CBC, chest x ray, auscultation of valves.

34
Q

How can cardiac catheterisation/angiography aid diagnosis of aortic stenosis?

A

Can identify elevated peak pressures in the left ventricle and aorta, which can be a sign of stenosis

35
Q

Why can a chest xray help diagnosis aortic stenosis?

A

Can show left ventricular hypertrophy, which is commonly associated with aortic stenosis

36
Q

What are the clinical signs of mitral stenosis?

A

Diastolic murmur, raised JVP, peripheral cyanosis, pulmonary oedema

37
Q

Why does mitral stenosis cause pulmonary oedema?

A

Increased left atrial pressure causes back pressure into the lungs

38
Q

Why can mitral stenosis cause dyspnoea?

A

Due to pulmonary oedema produced by elevated left atrial pressure

39
Q

Which infection precedes acute rheumatic fever?

A

Group A Streptococcal (GAS) pharyngitis

40
Q

How do GAS infections cause damage to heart valves?

A

the is cross-reactivity to antibodies against the M protein of GAS, with the connective tissue of the heart via a combination of antibody and CD4+ T cell mediated inflammation.

41
Q

What types of hypersensitivity are involved in the pathogenesis of acute rheumatic fever?

A

Type II (involving antibodies), Type IV (involving CD4+ T cells)

42
Q

What occurs to the heart during an episode of acute rheumatic fever?

A

Pancarditis - inflammation of all 3 layers of the heart (endocarditis, myocarditis, pericarditis)

43
Q

Why do repeated episodes of acute rheumatic fever cause valve damage?

A

There is fibrosis of the valves due to healing of repeatedly inflamed valves.

44
Q

What are the 2 types of deformity possible when valve commissures become fused in rheumatic heart disease?

A

Button-hole, fish-mouth

45
Q

What are the effects of rheumatic heart disease on the chordae tendineae?

A

Get thicker and shorter

46
Q

Which valve is most commonly affected by rheumatic heart disease?

A

The mitral valve

47
Q

What type of valve deformity is most common in rheumatic heart disease?

A

Mitral valve stenosis

48
Q

What are the clinical features of acute rheumatic fever?

A

Pancarditis, migratory polyarthritis, subcutaneous nodules, erythema marginatum, sydenham chorea

49
Q

What joint symptom occurs in rheumatic fever?

A

Migratory polyarthritis, where there is an episode at one joint, then it leaves and attacks another joint.

50
Q

Why does rheumatic fever cause subcutaneous nodules?

A

There is cross-reactivity with GAS and self antigens in subcutaneous tissue/

51
Q

What is erythema marginatum?

A

A rash, with well defined rings of erythema on the skin.

52
Q

What is sydenham chorea?

A

Symptom of rheumatic fever: involuntary, rapid, jerky movements, particularly of the hands

53
Q

What is the Jones Criteria used to diagnose?

A

Acute Rheumatic Fever

54
Q

What are the symptoms of the major criteria of the Jones Criteria?

A

Carditis, polyarthritis, chorea, erythema marginatum

55
Q

What are the symptoms of the minor criteria of the Jones Criteria?

A

Fever, polyarthralgia, previous rheumatic fever

56
Q

How mant many major and minor symptoms must be present for a diagnosis with the Jones Criteria?

A

2 major and 1 minor symptom .

57
Q

What do new New Zealand guidelines typically require to confirm diagnosis of acute rheumatic fever?

A

Echocardiography of valves, positive recent history of GAS pharyngitis

58
Q

What happens to the line of closure of valves in ARF?

A

Foci of endothelial injury and necrosis within the cusp line of closure

59
Q

What are the morphological features of valves damaged by ARF?

A

Formation of sterile, platelet-thrombi called verrucae on the line of closure of valves.

60
Q

What are the features of rheumatic myocarditis?

A

Myocardium becomes soft and flabby, causing chamber dilation. Aschoff bodies made of caterpillar cells form

61
Q

What is the appearance of the pericardium in ARF?

A

Bread-andbutter - covered in shaggy fibrin rich exudate.

62
Q

What component of rheumatic pancarditis produces a rub sound on auscultation?

A

Bread and butter pericarditis

63
Q

What is infective endocarditis?

A

An infection of the endocardium, characterised by colonisation of the heart valves by bacteria.

64
Q

What are the components of the vegetations in infective endocarditis?

A

Thrombotic debris, bacteria, inflammatory cells

65
Q

What are the complications of vegetations in infective endocarditis?

A

They may embolise (break off) and travel through the blood stream to cause septic infarcts in the brain, kidneys, etc.

66
Q

What are the 2 classifications of infective endocarditis?

A

Acute, subacute/long incubation

67
Q

What is the relative virulence of organisms causing acute infectious endocarditis?

A

High virulence

68
Q

What is the relative virulence of organisms causing subacute infectious endocarditis?

A

Low virulence

69
Q

Which bacteria most commonly causes subacute infective endocarditis in NZ?

A

Streptococcus viridans

70
Q

Where is Streptococcus viridans typically found?

A

Colonising the mouth, is low virulence

71
Q

Which type of infective endocarditis typically infects healthy valves?

A

Acute

72
Q

Which type of infective endocarditis typically infects diseased valves?

A

Subacute

73
Q

What are some of the key strategies for reducing the burden of Rheumatic Heart Disease?

A

making ARF a notifiable disease, public campaigns, sore throat detection programmes, patient education on symptoms/treatment of ARF, antibiotic prophylaxis for patients with ARF/RHD, addressing social determinants of health

74
Q

Why is antibiotic prophylaxis used for patients with rheumatic heart disease?

A

To prevent recurring episodes of ARF, and to prevent the development of infective endocarditis

75
Q

What antibiotic and administration is used as prophylaxis for RHD?

A

Injections of benzathine penicillin

76
Q

What is the key difference between ‘fair’ and ‘unfair’ reasons for elective surgery prioritisation ranking?

A

Fair things are based on clinical judgement, while unfair things are based on the personal circumstances of the patient and/or physician

77
Q

What factors are considered when ranking patients for elective surgery priority?

A

Degree of benefit they will receive, severity of condition, likelihood of survival, usage of recreational drugs, adherence to treatment.

ELM2 - integrated cases (9 decks)

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