Cardiovascular review

Cardiovascular review
Endocarditis

A 28 yrs old man is brought to ER because of fatigue

A 28 yrs old man is brought to ER because of fatigue
and fever of
and fever of
acute onset
acute onset
. He has a history of I/V drug
. He has a history of I/V drug
use. Echo suggests endocarditis of the tricuspid valve.
use. Echo suggests endocarditis of the tricuspid valve.
He has
He has
no
no
past history of valvular heart disease. lood
past history of valvular heart disease. lood
cultures are li!ely to gro"
cultures are li!ely to gro"

#treptococcus viridans
#treptococcus viridans

#taph Aureus
#taph Aureus

$reponema %allidum
$reponema %allidum

#treptococcus %yogenes
#treptococcus %yogenes

A drug addict presents "ith t"o "ee!s history of fever

A drug addict presents "ith t"o "ee!s history of fever
and chest pain. &n e'amination a
and chest pain. &n e'amination a
ne" systolic murmur
ne" systolic murmur

is heard at the ape'. Echocardiogram sho"s an
is heard at the ape'. Echocardiogram sho"s an
oscillating mass
oscillating mass
attached to the mitral valve. (hat is the
attached to the mitral valve. (hat is the
diagnosis)
diagnosis)

A *itral stenosis
A *itral stenosis

+ardiac failure
+ardiac failure

+ #epticemia
+ #epticemia

, Atrial my'oma
, Atrial my'oma

E Infective Endocarditis.
E Infective Endocarditis.
#ubacute b/c of e'isting
#ubacute b/c of e'isting
lesion of valve
lesion of valve
(hat nail/s!in lesion is found in this condition
(hat nail/s!in lesion is found in this condition

An i/v drug addict presents "ith fever and

pleuritic chest pain of one "ee!s duration. -ou
detect on e'amination a friction rub and a
murmur at the left .
th
interspace. most li!ely
diagnosis is

acterial endocarditis

%ericarditis

#epticemia

pneumonia

A ./ yrs old "oman complains of recurrent transient

A ./ yrs old "oman complains of recurrent transient
loss of consciousness and di00iness for 1 months. she
loss of consciousness and di00iness for 1 months. she
has fever2
has fever2
severe "t loss
severe "t loss
2 fatigue and breathlessness at
2 fatigue and breathlessness at
rest that is relieved in
rest that is relieved in
supine position and "orse on
supine position and "orse on
standing
standing
. &/e febrile2 pallor2 and clubbing.#3 is delayed
. &/e febrile2 pallor2 and clubbing.#3 is delayed
and soft. lo" pitched sound
and soft. lo" pitched sound
4plop
4plop
5 is heard in diastoli
5 is heard in diastoli
follo"ed by a rumbling murmur and findings vary "ith
follo"ed by a rumbling murmur and findings vary "ith
body position. Echo sho"s mass arising from atrial
body position. Echo sho"s mass arising from atrial
septum
septum

*itral Incompetence
*itral Incompetence

*itral #tenosis
*itral #tenosis

6t Atrial my'oma
6t Atrial my'oma

*itral valve prolapse

*itral valve prolapse
Hypertension/hypotension

A 7. yrs old man presents "ith attac!s of light

headedness and you detect a pulse of 88 and
bp33//8/ "hilst sitting. As soon as he gets up
his pulse is 32/ and bp 8//9/. most li!ely
diagnosis is postural hypotension

+ardiac arrhythmia

$IA

Intravascular volume depletion

:ormal finding

A diabetic presents "ith light headedness "hen he gets

A diabetic presents "ith light headedness "hen he gets
up from lying do"n position. His bp is 32//8/ "hen he
up from lying do"n position. His bp is 32//8/ "hen he
is lying do"n and 8//;/ "hen he stands up. He also
is lying do"n and 8//;/ "hen he stands up. He also
has urinary incontinence and E,. $he fall in bp is due
has urinary incontinence and E,. $he fall in bp is due
to
to

A Hypovolemia
A Hypovolemia

Anemia
Anemia

+ high blood glucose

+ high blood glucose

,
,
Autonomic neuropathy
Autonomic neuropathy

E drug induced
E drug induced

A ;/ yrs pt presents "ith high bp2 cardiomegaly2

A ;/ yrs pt presents "ith high bp2 cardiomegaly2
oliguria and "ea!ness. *anagement should
oliguria and "ea!ness. *anagement should
include
include

Reducing preload
Reducing preload

Reducing afterload
Reducing afterload
prop to %
prop to %

Increasing heart rate

Increasing heart rate

Increasing myocardial contractility

Increasing myocardial contractility

A 2/ yrs old pt presents "ith headache and light

A 2/ yrs old pt presents "ith headache and light
headedness. &n e'amination his femoral pulse is "ea!
headedness. &n e'amination his femoral pulse is "ea!
and delayed as compared to radial. p is 38//3// in the
and delayed as compared to radial. p is 38//3// in the
upper e'tremity and 3///;/ in the lo"er and <ray
upper e'tremity and 3///;/ in the lo"er and <ray
sho"s notching of the ribs. *ost li!ely diagnosis is
sho"s notching of the ribs. *ost li!ely diagnosis is

A
A
+oarctation of aorta====$>R:ER#
+oarctation of aorta====$>R:ER#

%atent ,uctus Arteriosus

%atent ,uctus Arteriosus

+ +ongenital aortic stenosis

+ +ongenital aortic stenosis

, +onns syndrome
, +onns syndrome

E %haeochromocytoma
E %haeochromocytoma
(hat genetic disease is this often associated "ith)
(hat genetic disease is this often associated "ith)

A 2. yrs old pt presents "ith

A 2. yrs old pt presents "ith
%aro'ysms
%aro'ysms
of
of
headache /palpitations/ hyperhydrosis/flushing p is
headache /palpitations/ hyperhydrosis/flushing p is
2///33/ and 2hrs later 37//8/
2///33/ and 2hrs later 37//8/
(hat is the diagnosis?
(hat is the diagnosis?
pheo)
pheo)
Ho" "ould you confirm==
Ho" "ould you confirm==

A 1/ yrs pt presents "ith fatigue/"ea!ness

A 1/ yrs pt presents "ith fatigue/"ea!ness
/polyurea /muscle cramps. p is 38//3// se @ 2..
/polyurea /muscle cramps. p is 38//3// se @ 2..
prim hyperaldosteronism +&::A#
prim hyperaldosteronism +&::A#

A lady "ith #6E

A lady "ith #6E
on prednisone
on prednisone
for ten yrs presents
for ten yrs presents
"ith hypertension and impaired glucose tolerance and
"ith hypertension and impaired glucose tolerance and
you detect a compression fracture of $3/
you detect a compression fracture of $3/
+>#HI:B
+>#HI:B

,uring repair of an abdominal aortic aneurysm the

,uring repair of an abdominal aortic aneurysm the
anesthesiologist inserts a balloon tipped catheter and
anesthesiologist inserts a balloon tipped catheter and
feeds it through to the patientAs
feeds it through to the patientAs
pulmonary artery
pulmonary artery
. once
. once
in position2 the balloon is inflated and the pressure is
in position2 the balloon is inflated and the pressure is
read. (hat pressure is he attempting to determine
read. (hat pressure is he attempting to determine

6eft Atrial pressure

6eft Atrial pressure

6eft ventricular end systolic pressure

6eft ventricular end systolic pressure

%ulmonary artery pressure

%ulmonary artery pressure

Right atrial pressure

Right atrial pressure

-ou have been a family physician of a couple

-ou have been a family physician of a couple
"ho have been trying to have a baby. $he
"ho have been trying to have a baby. $he
"oman visits your clinic for
"oman visits your clinic for
a pregnancy
a pregnancy
test and
test and
results are positive. (hat can you predict about
results are positive. (hat can you predict about
her blood pressure over the course of pregnancy
her blood pressure over the course of pregnancy

It "ill decrease
It "ill decrease

It "ill decrease then come bac! to baseline

It "ill decrease then come bac! to baseline

It "ill increase
It "ill increase

It "ill not change

It "ill not change

A pt is at emerg complaining of severe

A pt is at emerg complaining of severe
headache. on e'am his bp is 38//33/ and it is
headache. on e'am his bp is 38//33/ and it is
noted that 7 previous clinic readings over 2 yrs
noted that 7 previous clinic readings over 2 yrs
have been around 31//8/. an hr later it is
have been around 31//8/. an hr later it is
38//32/.on e'am you are li!ely to detect
38//32/.on e'am you are li!ely to detect
sudden
sudden
raise of %
raise of %

Radiofemoral delay in pulse

Radiofemoral delay in pulse

Assymetrical pulses
Assymetrical pulses

renal artery bruitC

renal artery bruitC
renal artery stenosis
renal artery stenosis

ounding pulse
ounding pulse
anatomy

A young man presents to ER after being involved in a

A young man presents to ER after being involved in a
fight. on e'amination2 a one inch
fight. on e'amination2 a one inch
stab
stab
"ound is noticed
"ound is noticed
at the fourth intercostal space Dust left of the sternum.
at the fourth intercostal space Dust left of the sternum.
"hich chamber of the heart is most li!ely to have been
"hich chamber of the heart is most li!ely to have been
penetrated by the !nife)
penetrated by the !nife)

6eft atrium
6eft atrium

6eft ventricle
6eft ventricle

Right atrium
Right atrium

Right ventricle ant most chamber

Right ventricle ant most chamber

A patient presents "ith H/& hypertension for 3/ yrs.

A patient presents "ith H/& hypertension for 3/ yrs.
(hile palpating the precordium2 a heave is identified at
(hile palpating the precordium2 a heave is identified at
the ape' "hich is located in the ;th intercostal space at
the ape' "hich is located in the ;th intercostal space at
the ant a'illary line. $his finding indicates
the ant a'illary line. $his finding indicates

*itral regurgitation
*itral regurgitation

Aortic stenosis
Aortic stenosis

6eft ventricular hypertrophy

6eft ventricular hypertrophy

%ericarditis
%ericarditis

Rt ventricular hypertrophy
Rt ventricular hypertrophy

A 2/ yrs lady comes to the clinic "ith severe shortness

A 2/ yrs lady comes to the clinic "ith severe shortness
of breath on e'ertion for 1 months. #he has a past
of breath on e'ertion for 1 months. #he has a past
medical history of +hronic &bstructive %ulmonary
medical history of +hronic &bstructive %ulmonary
,isease. &n e'amination she is found to have a
,isease. &n e'amination she is found to have a
left
left
parasternal heave
parasternal heave
2 raised EV%2 hepatomegaly and
2 raised EV%2 hepatomegaly and
peripheral edema. $he most li!ely cause of this heave is?
peripheral edema. $he most li!ely cause of this heave is?

a5 6eft ventricular hypertrophy

a5 6eft ventricular hypertrophy

b5
b5
Right ventricular hypertrophy===+&R
Right ventricular hypertrophy===+&R
%>6*&:A6E
%>6*&:A6E

c5 +ardiomegaly
c5 +ardiomegaly

d5 Hypertension
d5 Hypertension

e5 Hyperdynamic circulation
e5 Hyperdynamic circulation
*ost li!ely diagnosis is )
*ost li!ely diagnosis is )

A ;/ yrs old lady presents "ith 2/ yrs history of

A ;/ yrs old lady presents "ith 2/ yrs history of
Hypertension. For the last ; months has developed
Hypertension. For the last ; months has developed
fatigue2 dyspnea and an!le s"elling. &n e'amination
fatigue2 dyspnea and an!le s"elling. &n e'amination
she has pulse of 32/2 p 3;//8/2 raised EV% and faint
she has pulse of 32/2 p 3;//8/2 raised EV% and faint
#1 gallop. "hat maneuver "ill augment #1
#1 gallop. "hat maneuver "ill augment #1

Valsalva
Valsalva

6ying do"n
6ying do"n

#tanding
#tanding

#itting up leaning for"ard

#itting up leaning for"ard

Hand grip
Hand grip
4isometric e'ercise5
4isometric e'ercise5

A 1/ yrs lady complains of chest pain for 1 days.

A 1/ yrs lady complains of chest pain for 1 days.
you suspect costocondritis as cause of her chest
you suspect costocondritis as cause of her chest
pain. "hat e'amination techniGue "ill you use to
pain. "hat e'amination techniGue "ill you use to
confirm
confirm

Inspection
Inspection

%alpation
%alpation

%ercussion
%ercussion

auscultation
auscultation

A 1/ yrs pregnant lady2 chronic smo!er develops

A 1/ yrs pregnant lady2 chronic smo!er develops
dyspnoea and on e' has
dyspnoea and on e' has
loud %22
loud %22
rt ventricular
rt ventricular
heave 4lt parasternal heave5. #he is li!ely to have
heave 4lt parasternal heave5. #he is li!ely to have

*itral stenosis
*itral stenosis

%ulmonary hypertension
%ulmonary hypertension

+ardiac failure
+ardiac failure

High cardiac output

High cardiac output

A .8 yrs old man "ith *arfans syndrome presents "ith

A .8 yrs old man "ith *arfans syndrome presents "ith
abrupt onset of H
abrupt onset of H
tearingI chest pain radiating to the
tearingI chest pain radiating to the
bac!2 on e'amination? pallor2 diaphoretic2 % is 9//2/2
bac!2 on e'amination? pallor2 diaphoretic2 % is 9//2/2
asymmetric pulse2 declining mental status and +<R
asymmetric pulse2 declining mental status and +<R

"idened mediastinum
"idened mediastinum
. *ost li!ely diagnosis is
. *ost li!ely diagnosis is

A *ediastinal tumour
A *ediastinal tumour

*yocardial infarction
*yocardial infarction

+ Acute ,elirium
+ Acute ,elirium

, Aortic dissection
, Aortic dissection

E %ulmonary embolism
E %ulmonary embolism
%redisposing factors)
%redisposing factors)

A .. yrs old male complains of chest pain lasting . mts

A .. yrs old male complains of chest pain lasting . mts
that he had every fe" months "hen he "al!ed for 2
that he had every fe" months "hen he "al!ed for 2
bloc!s. this pain "ent a"ay "hen he stopped "al!ing.
bloc!s. this pain "ent a"ay "hen he stopped "al!ing.
For the last 3 month this pain occurs even "hen he is
For the last 3 month this pain occurs even "hen he is
Dust sitting and has happened . times this "ee! and
Dust sitting and has happened . times this "ee! and
lasted 3/mts.your diagnosis is
lasted 3/mts.your diagnosis is

Angina
Angina

*I
*I

>nstable angina
>nstable angina

%rin0metal angina
%rin0metal angina

A 1. yrs old lady has several attac!s of chest of non

e'ertional chest pain "ith palpitations. #he rushes every
time to a dr or ER "here her E+B is done and is
normal everytime. she suddenly got her attac! yesterday
in the bus and had to be rushed to hospital. she most
li!ely is having

Angina

*I

+onversion disorder

%anic attac!
Arrhythmias

An 8/ yrs old diabetic "ith hypertension and a history of An 8/ yrs old diabetic "ith hypertension and a history of
Rheumatic heart disease presents "ith left sided "ea!ness. &n Rheumatic heart disease presents "ith left sided "ea!ness. &n
e'amination pulses are e'amination pulses are irregularly irregular irregularly irregular2 Eugular veins sho" 2 Eugular veins sho"
absent absent HaI "aves HaI "aves and E+B sho"s and E+B sho"s absence of H%I "aves absence of H%I "aves *ost *ost
li!ely diagnosis is li!ely diagnosis is

A supra ventricular tachycardia A supra ventricular tachycardia

*ultiple %remature ventricular contractions *ultiple %remature ventricular contractions

+ + Atrial Fibrillation Atrial Fibrillation

, #inus arrythmia , #inus arrythmia

His past med record sho"s presence of #1 and #7."hat can you His past med record sho"s presence of #1 and #7."hat can you
e'pect to find no" e'pect to find no"
Absent #1 Absent #1
Absent #7 Absent #7
loud #1 loud #1
loud #7 loud #7

A 7/ yrs old lady presents "ith palpitations2 light

headed spells and breathlessness. you detect on
her E+B short %R interval and slurred JR#
upstro!es indicative of delta "ave. #he li!ely has

AV bloc!

Ventricular $achycardia

(%( syndrome 4supraventricular tachycardia5

*I

AF
Cardiac failure & cardiomyopathy

;. yrs old man "ith chronic hypertension complains of

;. yrs old man "ith chronic hypertension complains of
recurrent shortness of breath of 2 months. He is a
recurrent shortness of breath of 2 months. He is a
nonsmo!er. e'amination of the precordium is normal
nonsmo!er. e'amination of the precordium is normal
e'cept for a prominent apical impulse. echo sho"s
e'cept for a prominent apical impulse. echo sho"s
6VH. radionucleide ventriculography sho"s
6VH. radionucleide ventriculography sho"s
normal
normal
right and left eDection fractions4;/K5.
right and left eDection fractions4;/K5.
"hat has caused
"hat has caused
his symptoms
his symptoms

+or pulmonale
+or pulmonale

#ystolic heart dysfunction

#ystolic heart dysfunction

,iastolic dysfunction
,iastolic dysfunction

Reactive air"ay disease

Reactive air"ay disease

A 9/ yrs old patient "ith history of coronary artery

A 9/ yrs old patient "ith history of coronary artery
disease presents "ith "orsening dyspnea on e'ertion2
disease presents "ith "orsening dyspnea on e'ertion2
orthopnea and paro'ysmal nocturnal dyspnea. &n
orthopnea and paro'ysmal nocturnal dyspnea. &n
e'amination there is tachycardia2 #1 gallop2 bilateral
e'amination there is tachycardia2 #1 gallop2 bilateral
crac!les. +'ray sho"s cardiomegaly and bilateral @erley
crac!les. +'ray sho"s cardiomegaly and bilateral @erley
lines.
lines.
EDection fraction is 2/ K
EDection fraction is 2/ K
Hemodynamics
Hemodynamics
associated "ith this condition includes
associated "ith this condition includes

A increased Rt ventricular preload

A increased Rt ventricular preload

increased left ventricular preload

increased left ventricular preload

+ decreased left ventricular preload

+ decreased left ventricular preload

, Increased rt ventricular afterload

, Increased rt ventricular afterload

E increased left ventricular afterload

E increased left ventricular afterload

A ;/ yrs old patient presents "ith shortness of breath2

fatigue and s"elling of his abdomen and feet for .
months. He is a heavy smo!er. on e'amination you
detect raised EV%2 hepatomegaly2 ascites and
paedeledema. +hest is clear. $he cause of his edema is

6VF

Increased plasma oncotic pressure

,ecreased plasma oncotic pressure in liver cirrhosis

+orpulmonale

Venous insufficiency

A ./ yrs hypertensive pt presents "ith edema

and is diagnosed "ith ++F and put on Ramipril2
atenolol2 diuretic 4frusemide52 digo'in and slo"
!. His edema "orsens so spironolactone is
added. "hich drug should no" be stopped.

,igo'in

Frusemide

#lo" !

atenolol

A 2. yrs A 2. yrs lady delivers lady delivers normally and develops breathlessness2 normally and develops breathlessness2
fatigue and s"elling of her feet to"ard the end of the day 2 fatigue and s"elling of her feet to"ard the end of the day 2
"ee!s after delivery. she has raised EV%2 heaving apical impulse "ee!s after delivery. she has raised EV%2 heaving apical impulse
displaced laterally and systolic murmurs at ape' and tricuspid displaced laterally and systolic murmurs at ape' and tricuspid
areas2#12#7. she also has tender hepatomegaly2 basal rhales and areas2#12#7. she also has tender hepatomegaly2 basal rhales and
pedeledema. +'ray sho"s cardiomegaly2 pulmonary edema and pedeledema. +'ray sho"s cardiomegaly2 pulmonary edema and
eDection fraction is 7/K.#he li!ely has eDection fraction is 7/K.#he li!ely has

,ilated cardiomyopathy ,ilated cardiomyopathy

Hypertrophic &bstructive cardiomyopathy Hypertrophic &bstructive cardiomyopathy

Restrictive cardiomyopathy Restrictive cardiomyopathy

+ardiac failure +ardiac failure

(hat type of cardiac dysfunction does she have) (hat type of cardiac dysfunction does she have) systolic systolic
(hat type of cardiomyopathy "ill alcoholics and pts "ith $hiamine (hat type of cardiomyopathy "ill alcoholics and pts "ith $hiamine
def have def have

A young athlete presents for evaluation "ith lo" blood

A young athlete presents for evaluation "ith lo" blood
pressure2 bradycardia2 Resp rate 32 and a
pressure2 bradycardia2 Resp rate 32 and a
systolic
systolic
murmur along the left lo"er sternal border.
murmur along the left lo"er sternal border.
"hat
"hat
condition do you "ant to rule out before you allo" him
condition do you "ant to rule out before you allo" him
to participate in athletics )
to participate in athletics )

H&+*
H&+*
efore valsalva
efore valsalva

,ilated cardiomyopathy
,ilated cardiomyopathy

Restrictive cardiomyopathy
Restrictive cardiomyopathy

:ormal finding in athlete after valsalva

:ormal finding in athlete after valsalva

Aortic stenosis
Aortic stenosis
Valsalva and standing venous return
Valsalva and standing venous return
Inspiration and sGuatting venous return
Inspiration and sGuatting venous return
E'ercise bp/cardiac output/gallops
E'ercise bp/cardiac output/gallops
A#
E'amination of a patients carotid pulse reveals E'amination of a patients carotid pulse reveals 2 2
impulses impulses in AR and *# in AR and *# or pea!s in a patient during ventricular or pea!s in a patient during ventricular
systole. (hich of the follo"ing physical findings systole. (hich of the follo"ing physical findings
probably "ill be associated "ith this pulse) probably "ill be associated "ith this pulse)

A rumbling diastolic murmur beginning "ith an &pening snap A rumbling diastolic murmur beginning "ith an &pening snap
*# *#

,ecrease in systolic pressure during inspiration ,ecrease in systolic pressure during inspiration pulsus parado'ic2 pulsus parado'ic2
cardiac temponade cardiac temponade

EDection #ystolic murmur along lt sternal border in H+*=== EDection #ystolic murmur along lt sternal border in H+*===
ans"er ans"er

%an systolic murmur at ape' %an systolic murmur at ape' *R *R

6eft sided #1 6eft sided #1 cardiac failure cardiac failure

Split S2
A 2; yrs old lady2 asymptomatic2 comes for a
A 2; yrs old lady2 asymptomatic2 comes for a
physical e'am and is found to have heart sounds
physical e'am and is found to have heart sounds
as sho"n and a systolic murmur in the %ulmonic
as sho"n and a systolic murmur in the %ulmonic
area
area
E'piration #3 A2 %2 inspiration #3 A2 %2
E'piration #3 A2 %2 inspiration #3 A2 %2

%ulmonary #tenosis
%ulmonary #tenosis

6
6

+oarctation of aorta
+oarctation of aorta

Atrial #eptal ,efect===embryo? septum

Atrial #eptal ,efect===embryo? septum
primum2secundum2 sinus venosus
primum2secundum2 sinus venosus

Aortic stenosis
Aortic stenosis
A ; yrs old child presents for routine e'amination at a
A ; yrs old child presents for routine e'amination at a
clinic and is found to have a systolic murmur at the left
clinic and is found to have a systolic murmur at the left
second intercostal space near the sternum. His heart
second intercostal space near the sternum. His heart
sounds are as follo"s. (hat is the most li!ely
sounds are as follo"s. (hat is the most li!ely
diagnosis) insp #3 A2 %2 e'p #3 A2 %2
diagnosis) insp #3 A2 %2 e'p #3 A2 %2

A Innocent murmur
A Innocent murmur

A#,
A#,

+ Aortic stenosis
+ Aortic stenosis

, %ulmonic #tenosis====RC*RC*V%)
, %ulmonic #tenosis====RC*RC*V%)

E 6eft bundle branch bloc!

E 6eft bundle branch bloc!
(hat other conditions can have this split
(hat other conditions can have this split

A 7/ yrs old man complains of palpitation and

A 7/ yrs old man complains of palpitation and
light headedness off and on for 1 "ee!s. He had
light headedness off and on for 1 "ee!s. He had
a myocardial infarction 2 months ago. &n
a myocardial infarction 2 months ago. &n
auscultation you hear
auscultation you hear


Inspiration e'piration
Inspiration e'piration


#3 #2 #3 %2A2
#3 #2 #3 %2A2

A child attends a "ell baby clinic and the dr

A child attends a "ell baby clinic and the dr
detects a soft systolic murmur at the left second
detects a soft systolic murmur at the left second
interspace.#2 has a split during inspiration
interspace.#2 has a split during inspiration
only.
only.
most li!ely diagnosis is
most li!ely diagnosis is

A#,
A#,

%ulmonic stenosis
%ulmonic stenosis

Innocent murmur
Innocent murmur

R
R
Valvular disease

A 2/ yrs old man diagnosed "ith *arfans syndrome A 2/ yrs old man diagnosed "ith *arfans syndrome
complains of fatigue and shortness of breath. &/E you notice complains of fatigue and shortness of breath. &/E you notice
his his head nodding2 collapsing pulse2 detect a "ide pulse head nodding2 collapsing pulse2 detect a "ide pulse
pressure p 432//7/5 and his phonocardiogram is as follo"s. pressure p 432//7/5 and his phonocardiogram is as follo"s.
(hat is the most li!ely diagnosis) (hat is the most li!ely diagnosis)

A *itral stenosis A *itral stenosis

$ricuspid regurgitation $ricuspid regurgitation

+ + Aortic Incompetence Aortic Incompetence

, Innocent murmur , Innocent murmur

E %atent ,uctus Arteriosus E %atent ,uctus Arteriosus

(here "ill you hear this murmur (here "ill you hear this murmur
(hat position "ill accentuate this murmur) (hat position "ill accentuate this murmur)
(hat conditions predispose to this abnormality (hat conditions predispose to this abnormality

A 9/ yrs old diabetic "ith hypercholesterolemia

A 9/ yrs old diabetic "ith hypercholesterolemia
presents "ith angina2 syncope2 dyspnoea on e'ertion.
presents "ith angina2 syncope2 dyspnoea on e'ertion.
&n e'amination his carotid pulse is diminished2 slo"ly
&n e'amination his carotid pulse is diminished2 slo"ly
rising and there is a crescendo=decrescendo systolic
rising and there is a crescendo=decrescendo systolic
murmur at second intercostal space at the right upper
murmur at second intercostal space at the right upper
sternal border2 radiating to the nec! phonocardiogram
sternal border2 radiating to the nec! phonocardiogram
is as sho"n *ost li!ely diagnosis is
is as sho"n *ost li!ely diagnosis is

A +arotid atherosclerosis
A +arotid atherosclerosis

+ Hypertrophic obstructive cardiomyopathy

+ Hypertrophic obstructive cardiomyopathy

, Aortic #tenosis
, Aortic #tenosis

E %ulmonic #tenosis
E %ulmonic #tenosis

An i/v drug user presents "ith chest pain and

An i/v drug user presents "ith chest pain and
shortness of breath. you detect raised EV% and
shortness of breath. you detect raised EV% and
large v "aves
large v "aves
as "ell as holosytolic murmur at
as "ell as holosytolic murmur at
left 7 ics2
left 7 ics2
pulsating liver
pulsating liver
and edema. diagnosis is
and edema. diagnosis is

$ricuspid stenosis
$ricuspid stenosis

*itral stenosis
*itral stenosis

$ricuspid regurgitation
$ricuspid regurgitation

+omplete heart bloc!

+omplete heart bloc!

A 12 yrs old teacher is referred to your clinic for

A 12 yrs old teacher is referred to your clinic for
evaluation of non e'ertional
evaluation of non e'ertional
chest pain
chest pain
. #he
. #he
appears an'ious and has occasional
appears an'ious and has occasional
s!ipped
s!ipped
beats
beats
and
and
fatigue
fatigue
. %redict the findings you are
. %redict the findings you are
li!ely to detect &n e'amination.
li!ely to detect &n e'amination.

A early diastolic murmur in the aortic area

A early diastolic murmur in the aortic area

midsystolic clic!2 late systolic murmur

midsystolic clic!2 late systolic murmur

+ signs of +ardiac failure

+ signs of +ardiac failure

, #1 and #7
, #1 and #7

E midsystolic murmur in the Aortic area

E midsystolic murmur in the Aortic area

A 1/ yrs old female presents "ith shortness of breath

A 1/ yrs old female presents "ith shortness of breath
after e'ertion of ; months duration. #he "as diagnosed
after e'ertion of ; months duration. #he "as diagnosed
"ith Rheumatic fever in childhood. you detect the
"ith Rheumatic fever in childhood. you detect the
follo"ing
follo"ing
rumbling diastolic murmur
rumbling diastolic murmur
on auscultation
on auscultation
*ost li!ely diagnosis is
*ost li!ely diagnosis is

A A#,
A A#,

*itral Incompetence
*itral Incompetence

+ $ricuspid Incompetence
+ $ricuspid Incompetence

, *itral #tenosis
, *itral #tenosis

A 2. yrs old patient has cough2 shortness of

A 2. yrs old patient has cough2 shortness of
breath and fatigue for ; months. +ardiac
breath and fatigue for ; months. +ardiac
catheteri0ation reveals a pressure of 3; mm in
catheteri0ation reveals a pressure of 3; mm in
the left atrium and 7 mm end diastolic in left
the left atrium and 7 mm end diastolic in left
ventricle. $his is most li!ely due to
ventricle. $his is most li!ely due to

Rheumatic heart disease

Rheumatic heart disease

Ischemic heart disease

Ischemic heart disease

+ongenital heart disease

+ongenital heart disease

cardiomyopathy
cardiomyopathy
Congenital heart disease

A 31 months old baby presents "ith paro'ysms of dyspnea A 31 months old baby presents "ith paro'ysms of dyspnea
follo"ed by loss of consciousness for 3=2 minutes. #he is often follo"ed by loss of consciousness for 3=2 minutes. #he is often
seen sGuatting after playing. &/E you detect clubbing2 central seen sGuatting after playing. &/E you detect clubbing2 central
cyanosis2 a lt parasternal heave and an eDection systolic murmur cyanosis2 a lt parasternal heave and an eDection systolic murmur
at left 2nd intercostal space Her chest 'ray sho"s a boot shaped at left 2nd intercostal space Her chest 'ray sho"s a boot shaped
heart and heart and decreased pulmonary vascularity decreased pulmonary vascularity. $his is due to . $his is due to

#eptum secondum def #eptum secondum def

>neGual division of $runcus Arteriosus by conotruncal septum >neGual division of $runcus Arteriosus by conotruncal septum

Endocardial cushion def Endocardial cushion def

6ooping defect 6ooping defect

spiraling defect spiraling defect

A 2 yrs old child2 has severe stridor and dysphagia.
A 2 yrs old child2 has severe stridor and dysphagia.
Assuming she has a vascular ring this is
Assuming she has a vascular ring this is
embryologicaly due to
embryologicaly due to

Improper spiraling of the septum

Improper spiraling of the septum

6ooping defect
6ooping defect

Endocardial cushion defect

Endocardial cushion defect

Aortic arch defect

Aortic arch defect

A neonate 47!gs birth "eight5 born of diabetic mother

A neonate 47!gs birth "eight5 born of diabetic mother
is seen to have severe cyanosis and is diagnosed "ith
is seen to have severe cyanosis and is diagnosed "ith
cyanotic congenital heart disease.
cyanotic congenital heart disease.
prostaglandin E
prostaglandin E
is
is
given as the baby is prepared for surgery. most li!ely
given as the baby is prepared for surgery. most li!ely
diagnosis is
diagnosis is

Fallots tetralogy
Fallots tetralogy

$ricuspid Atresia
$ricuspid Atresia

$ransposition of the great ArteriesC#%IR6I:B defect

$ransposition of the great ArteriesC#%IR6I:B defect

Hypoplastic ventricle
Hypoplastic ventricle
(hat embryological defect has caused this
(hat embryological defect has caused this

A 2 days old baby2 born by ceasarean section is

noted to have blue lips and tongue and on
auscultation has a systolic murmur. c'ray sho"s
an enlarged heart. *ost li!ely diagnosis is

%,A

+oarctation of Aorta

icuspid Aortic valve

$ransposition of the Breat arteries

A five month old girl is breathless after feeds. #he

A five month old girl is breathless after feeds. #he
"as born full term and is alert. E'amination reveals a
"as born full term and is alert. E'amination reveals a
loud holosystolic murmur in left lo"er parasternal
loud holosystolic murmur in left lo"er parasternal
region2 no cyanosis/clubbing. phonocardiogram is as
region2 no cyanosis/clubbing. phonocardiogram is as
sho"n. +atheteri0ation sho"s increased o'ygen
sho"n. +atheteri0ation sho"s increased o'ygen
saturation in the rt ventricle (hich is the most li!ely
saturation in the rt ventricle (hich is the most li!ely
diagnosis)
diagnosis)

A#,
A#,

%,A
%,A

%atent Foramen &vale

%atent Foramen &vale

%ulmonic stenosis
%ulmonic stenosis

V#,
V#,

A 2 yrs boy born premature presents "ith shortness of

A 2 yrs boy born premature presents "ith shortness of
breath after playing. &n e'amination you detect dilated
breath after playing. &n e'amination you detect dilated
pulsating nec! vessels a
pulsating nec! vessels a
pulse pressure of 8/
pulse pressure of 8/
and a loud
and a loud
machinery murmur
machinery murmur
as sho"n at the left first to third
as sho"n at the left first to third
intercostal space. *ost li!ely diagnosis is
intercostal space. *ost li!ely diagnosis is

A V#,
A V#,

Fallots tetralogy
Fallots tetralogy

+ A#,
+ A#,

, %atent ductus arteriosus

, %atent ductus arteriosus
(hat drug is tried before surgery
(hat drug is tried before surgery
(hat maternal condition is associated "ith this
(hat maternal condition is associated "ith this
A 3/ yrs old girl diagnosed "ith Fallots tetralogy
dies and autopsy is done. $his is li!ely to reveal

A#,

,ecreased pulmonary vascularity

Increased pulmonary vascularity

6eft Atrial hypertrophy

6eft ventricular hypertrophy

A child is born "ith craniofacial abnormalities2

A child is born "ith craniofacial abnormalities2
hypoplasia of thymus and hypoparathyroidism and
hypoplasia of thymus and hypoparathyroidism and
cyanotic congenital heart disease. maldevelopment of
cyanotic congenital heart disease. maldevelopment of
"hich structure results in this defect
"hich structure results in this defect

Aortic arches
Aortic arches

Endocardial cushion
Endocardial cushion

:eural crest cells

:eural crest cells

+ardiac looping
+ardiac looping
(hich cardiac defect is associated "ith this syndrome
(hich cardiac defect is associated "ith this syndrome
Summary: Congenital efects

A#,? septum primum/secundum/sinus venosus

V#,? endocardial cushion defect

%ersistent $runcus Arteriosus? ulbus cordis 4absent

conotruncal4aortico=pulmonary septum5

$ransposition of BA? spiralling defect

,e'trocardia L+orrected $BA? looping defect

Fallots tetralogy? uneGual division of $runcus

Arteriosus resulting in narro" %A and "ide Aorta

Vascular ring ? Aortic arch defect

!ericardial disease

A 79 yrs old man had a myocardial infarction 1 days

A 79 yrs old man had a myocardial infarction 1 days
ago and "as recovering. suddenly develops
ago and "as recovering. suddenly develops
hypotension. &/E pulse is 32/2 "ea! and thready2
hypotension. &/E pulse is 32/2 "ea! and thready2
tachypnec2 pale2 cool s"eaty s!in2
tachypnec2 pale2 cool s"eaty s!in2
p 8//./ "hich is
p 8//./ "hich is
noted as ;//1/ during inspiration2
noted as ;//1/ during inspiration2
EV% is raised2 chest
EV% is raised2 chest
clear and heart sounds are muffled. +'ray sho"s
clear and heart sounds are muffled. +'ray sho"s
globular heart shado". *ost li!ely diagnosis is
globular heart shado". *ost li!ely diagnosis is

A %ulmonary edema
A %ulmonary edema

%ericarditis
%ericarditis

+ +ardiac $amponade
+ +ardiac $amponade

, 6
, 6

E Hypovolemia
E Hypovolemia

A 29 yrs old man presents to the ER after e'periencing

A 29 yrs old man presents to the ER after e'periencing
substernal chest pain radiating to the arm. $he pain is
substernal chest pain radiating to the arm. $he pain is
"orse on inspiration and relieved by leaning for"ards
"orse on inspiration and relieved by leaning for"ards
.
.
He says he recently recovered from an upper
He says he recently recovered from an upper
respiratory infection. &/E pulse is 32/2 p 32//9/
respiratory infection. &/E pulse is 32/2 p 32//9/
+ardiac e'am reveals a
+ardiac e'am reveals a
friction rub
friction rub
and distant heart
and distant heart
sounds. E+B sho"s elevated #$ segments across all
sounds. E+B sho"s elevated #$ segments across all
the chest leads. *ost li!ely diagnosis is
the chest leads. *ost li!ely diagnosis is

A Acute myocardial infarction

A Acute myocardial infarction

%ericarditis
%ericarditis

+ +ardiac $amponade
+ +ardiac $amponade

, %leurisy
, %leurisy

E Viral myocarditis
E Viral myocarditis
(hat is the causative organism
(hat is the causative organism

A 9/ year old "oman presents to you "ith shortness

A 9/ year old "oman presents to you "ith shortness
of breath2 fatigue2 and abdominal distension.3/ years
of breath2 fatigue2 and abdominal distension.3/ years
ago she under"ent a lumpectomy for left breast
ago she under"ent a lumpectomy for left breast
carcinoma2 follo"ed by ; "ee!s of local radiotherapy.
carcinoma2 follo"ed by ; "ee!s of local radiotherapy.
&/E she has a raised EV% "hich increases
&/E she has a raised EV% "hich increases
"ith
"ith
inspiration 4!ussmauls sign5
inspiration 4!ussmauls sign5
2 % 88/9&2
2 % 88/9&2
reduced
reduced
pulse pressure
pulse pressure
2 a "ea! pulse. Her
2 a "ea! pulse. Her
heart sounds are
heart sounds are
faint
faint
and she has ascites2 hepatomegaly and
and she has ascites2 hepatomegaly and
paedeledema. "hat is the most li!ely diagnosis)
paedeledema. "hat is the most li!ely diagnosis)

b5 $racheobronchial obstruction
b5 $racheobronchial obstruction

c5 &vermedicated "ith her antihypertensives

c5 &vermedicated "ith her antihypertensives

d5 6ate onset asthma

d5 6ate onset asthma

e5 +onstrictive pericarditis
e5 +onstrictive pericarditis

A ;/yrs old patient presents to ER "ith acute onset of shortness A ;/yrs old patient presents to ER "ith acute onset of shortness
of breath and severe stabbing chest pain.. He under"ent a of breath and severe stabbing chest pain.. He under"ent a
prostatectomy 1 "ee!s ago and prostatectomy 1 "ee!s ago and "as in bed for 2 "ee!s "as in bed for 2 "ee!s as he as he
developed surgical "ound infection . &/E you find him in developed surgical "ound infection . &/E you find him in
severe respiratory distress "ith p 8//;/ Heart rate 33//mt severe respiratory distress "ith p 8//;/ Heart rate 33//mt
respiratory rate 7//mt &'ygen saturation of 99K on room air. respiratory rate 7//mt &'ygen saturation of 99K on room air.
He is cyanosed2 EV% is raised2 trachea is central and reath He is cyanosed2 EV% is raised2 trachea is central and reath
sounds are reduced on the right side. E@B?#3J1$1 *ost li!ely sounds are reduced on the right side. E@B?#3J1$1 *ost li!ely
diagnosis is diagnosis is

A Rt %leural Effusion A Rt %leural Effusion

Acute *I Acute *I

+ %ericarditis + %ericarditis

, Rt 6obar %neumonia , Rt 6obar %neumonia

E E %ulmonary Embolism %ulmonary Embolism

A .. yrs old construction "or!er presents for

A .. yrs old construction "or!er presents for
evaluation of painful legs. He smo!ed 2 p!ts cigarettes
evaluation of painful legs. He smo!ed 2 p!ts cigarettes
daily since age 3..He has noticed pain in both buttoc!s
daily since age 3..He has noticed pain in both buttoc!s
and legs "hen "al!ing relieved "ith resting for 3/
and legs "hen "al!ing relieved "ith resting for 3/
minutes. &/E dorsalis pedis2 femoral pulses are absent
minutes. &/E dorsalis pedis2 femoral pulses are absent
bilaterally but radial is present. His feet are cool2 no
bilaterally but radial is present. His feet are cool2 no
edema and less hair gro"th. *ost li!ely diagnosis is
edema and less hair gro"th. *ost li!ely diagnosis is

A ,V$
A ,V$

Aortoiliac bifurcation occlusion

Aortoiliac bifurcation occlusion

+ coarctation of Aorta
+ coarctation of Aorta

, Femoral artery obstruction

, Femoral artery obstruction

A 1/ yrs old pt sustains gunshot "ound over the

A 1/ yrs old pt sustains gunshot "ound over the
femoral region and undergoes surgery.1 months
femoral region and undergoes surgery.1 months
later at follo" up he is seen to have a bruit and
later at follo" up he is seen to have a bruit and
thrill over the same region.
thrill over the same region.

Aneurysm
Aneurysm

AV fistula
AV fistula

&cclusion
&cclusion

#urgical scar
#urgical scar
$race the seGuence of valvular events after the %
$race the seGuence of valvular events after the %
"ave on the E+B
"ave on the E+B

A +losure of *itral/tricuspid2 follo"ed by

A +losure of *itral/tricuspid2 follo"ed by
opening of Aortic/pulmonic2 closure of A/%
opening of Aortic/pulmonic2 closure of A/%
finally opening of */$
finally opening of */$

closure of A/% foll by opening */$ then

closure of A/% foll by opening */$ then
closure of */$ finaly opening A/%
closure of */$ finaly opening A/%

+ closure of */$ foll by op of */$ then clos

+ closure of */$ foll by op of */$ then clos
of A/% foll by op of A/%
of A/% foll by op of A/%