panre and pance review cardiovascular i
DESCRIPTION
Certification and Recertification Exam Review Physician Assistant CardiovascularTRANSCRIPT
Cardiovascular I
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Dr. Donald Sefcik
Donald J. Sefcik is the Associate Dean at the Chicago College ofOsteopathic Medicine (CCOM), Midwestern University (MWU), inDowners Grove, IL. He is a tenured professor and board certified in bothEmergency Medicine and Family Medicine. From June L997 through May2000, Dr. Sefcik served as Medical Director for the Physician AssistantProgram, College of Health Sciences (CHS), at MWU. Dr. Sefcik's lecturesare based upon his experiences as a clinician and preceptor, tenure as a
medical school faculty member, and his student assessment research.
Dr. Sefcik has practiced with physician assistants since 1988 and beeninvolved in the clinical training of physician assistants since 1990. Prior tojoining lVlidwestern Universrty's faculty, Dr. Sefcik was a faculty member inthe Pharmacology Department at Butler University and in the NursingDepartment at Marian College, both in Indianapolis, Indiana. Dr. Sefcik hasa Bachelor of Science in Pharmacy (1981), a Master of Science inPharmacology (1994), both from Butler University, ffid an MBA (May2004) from Purdue University.
CME ResourcesCertification & Recertification Exam Review
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CertiJication & RecertiJication Exam ReviewCME Resources
2004
Cardiovascular Medicine - IDiagnostic Modalities and Murmurs
Donald J. Sefcik, D.O., FACOEPLearning Objectives
Upon completion of this portion of the review course, the participant should be able to:
L Discuss the following common cardiovascular diagnostic tools:Chest x-rays
o Electrocardiographs(EKC). ExerciseElectrocardiography(StressTests). Echocardiography. CardiacCatheterizationo Ultrafast CT scans
2. Differentiate left-sided and right-sided heart murmurs.3. Compare and contrast the following systolic and diastolic murmurs:
r Aortic stenosise Aortic regurgitationo Mitral stenosiso Mitral regurgitation (including MVP; Barlow's syndrome). Right-sided valvular defects
4. Define and describe Rheumatic heart disease.o Discuss Jones criteria.
5. Discuss endocarditis and its classic features.6, Compare and contrast Roth spots, Osler's nodes and Janeway lesions.
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Certification and Recertification Exam ReviewCardiology - I
2004
Case 1
A 64 year-old female presents complaining of crushing chest pain. She also advises youthat she is nauseous and is experiencing indigestion. She is notably diaphoretic. Herblood pressure is 124178 mm Hg. Her 12lead EKG reveals regional ST segmentelevation, Her rhythm strip is included for your interpretation.
Case 1 .1
Which one of the following myocardial infarctions is most likely?
A. anterior aspect of the left ventricleB. posterior aspect of the right ventricleC. inferior aspect of the left ventricleD. lateral aspect of the left ventricleE. anteriolateral aspect of the left ventricle
Case 1.2Which one of the following best describes the rhythm strip?
A. first degree AV blockB. second degree AV block, Mobitz type I - i,"., tl ir'' tr'"r'ir:'t L{'*
C. second degree AV block, Mobitz type llD. complete heart blockE. Wolf-Parkinson-White syndrome
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Certification and Recertification Exam ReviewCardiology - I
2004
Gase 2
A 36 year-old male presents complaining o{lgft-qggq ngrnlgqs for the past severalhours. He relates that he is in excellent heailh-?ndmsnTseen a clinician since highschool. His examination reveals murmurs, loudest at the aortic listening post,grades lllA/l systolic and llful diastolic.
Case 2.1Which one of the following would most expeditiouslydiagnosis?
A. echocardiogramB. fundoscopic examinationC. examination of peripheral pulses /D. complete neurological examinationE. CT scan of his brain
provide support for your initial
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\ ff tfre patient began to complain of a headache during your evaluation and then became'obtunded, which of the following would you suspect as the most likely cause?
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rupture of a berry aneurysmcw^. ,n :;;Ze- -- c.[*t,'*E;c rX \{10 \
marked ischemia of the left parietal lobemarked ischemia of the right occipitat loUet) nr + .\e{ie *,9West Nile Viral encephalopathy
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Certification and Recertification Exam ReviewCardiologY - I
2004
Case 3
A 62 year-old female presents complaining of palpitations. She has experienced two
previous episodes that lasted only a few minutes. This episode has lasted two hours' She
is mildly short of breath, mostly because of anxiety. She denies chest pain. Her rhythm
strip is included for your interpretation.
A. quinidine t ^B. lidocaine - c^\ *!f..'\rz -*'C. amiodarone'v*-*..-r,aD. diltiazem r\1:,'yllr,'n'ta:.E. digoxin "
Case 3.1Wnic-f' one of the following therapeutic choices would be LEAST effective
this arrhythmia?
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Case 3.2Which one of the following diagnostic tests would be the most
definitive diagnosis underlying her arrhythmia?
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A. complete blood countB. free serum Ta levelC. 24 hour holter monitorD. HDL cholesterol levelE. serum potassium level
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Certification and Recerti{ication Exam ReviewCardiology - I
2004
Gase 4
A 56 year-old male presents complaining of severe tightness in his chest for 45 minutes. Heis a smoker, with longstanding hypertension, diabetes mellitus type 2 and hyperlipidemia.His EKG reveals ST segment elevation (4 mm) and T wave changes.
Case 4.1Which one of the following, if identified on this patient's EKG, supports the diagnosis ofacute myocardial infarction with a positive predictive value of greater than 90%?
A. R waves greater than 11 mm in height in tead avf {LV qA asymmetric T wave inversionLeJ reciprocal sr segment depression ,i;f e\zurr\r-:,,-r =D. multifocal premature atrial complexes v I . r
E. unifocal premature ventricular complexes 'Tt.,r.,,;murA ric\'\c"r','c.
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Case 4.2lf this patient is not having an acute myocardial infarction, which one of the following isLEAST likely the correct diagnosis?
@ rate-related event - g€o e$ w''\ S,\"e-B. myocarditis
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-E. acute pericarditis c/
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Certification and Recertification Exam ReviewCardiology - I
2004
Case 5
A 62 year-old male presents complaining of_sho of breath on exertion for thepast several weeks; now he is short of breath at resl congestiveheartfaiIure.HisexaminationlffiS,SinuStachycardia,bilate-rallowerextremity edema (3+/4+), indirect (bedside) evidence of elevated right atrial pressureand a heart gallop.
Case 5.1Which one of the following is the most specific manifestation supporting a currentdiagnosis of congestive heart failure in this patient?
A. bibasilar ralesB. atrialgallopC. ventricular gallopD. jugular venous distentionE. peripheral edema
@such patients are preload dependent.B. most diuretics are negative inotropes.C. most diuretics are positive chronotropes.D, the ensuing vasoconstriction will reduce peripheral resistance.E. the baroreceptor reflexive response will be bradycardia.
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Case 5.2This patient has documented diastolic dysfunction. Aggressive diuresis in this patientmight cause hypotension because:
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C e rtificatio n and Recertificatio n Exam ReviewCardiology - I
2004
Gase 6
A 64 year-old female presents to your practice for her first visit. She had a myocardialinfarction two years ago. She currently is asymptomatic, just wants to establish rappotlwith a clinician in her new neighborhood. Her blood pressure is 122174 mm Hg and herpulse is 64. Her total cholesterol is 230, with an LDL of 130. Her BMI is 24. She has noother medical problems. She follows a low fat diet and walks briskly in the mall every day.
Case 6.1
Which one of the following is the most appropriate at this time?
A. no intervention is required
@tart lovastatinC. start cholestyramineD. start metoprololE. order an echocardiogram
Case 6.2Six weeks later the patient presents to the Emergency Depadment complaining of 45minutes of crushing chest pain. She has 4 mm of ST segment elevation in leads ll, llland aVF. Her blood pressure is 142182 mm Hg and pulse is 72. Based only upon whatis known, which of the following should NOT be administered to this patient?
A. aspirin
@diltiazemC. metoprololD. oxygen (2 liters)E. a thrombolytic agent
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Certificatio n and Recertifrcation Exam ReviewCardiology - I
2004
Case 7
A 68 year-old female presents to your practice complaining of dyspnea on exertion.She advises you that the symptoms began about four weeks ago. She denies chestpain, dizzine_sq qnd orthopnea. During her examination, you auscultate a grade lllA/lelectiorGvsto.l*urmur that radiates into her carotids and into her axilla (loudest in theleft-lateral decubitus position). \
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cause of the murmur that you hear?Case 7.1Which one of the following is most likely a
A. aorlic regurgitation -b,tr>tB. mitral regurgitatiop - -slsrui',L-C. pulmonic regurgitation rr nD. iricuspid ste-nos-is ) l)'cn'sotlcE. Austin-Flint murmur
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Case 7 .2Which of the following sets of EKG findings would you expect to find on her EKG?
A. low voltage and sinus tachycardiaB. R waves in lead V5 less than 10 mm in height and right axis deviationC. S waves in lead V2 less than 5 mm in height and left axis deviationD. right atrial enlargement and right axis deviationE. P waves in lead ll greater than 3 mm in width and P waves in lead V1
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Certification and Recertification Exam ReviewCardiology - I
2004
Case 8
, SNI_A patient is noted tofauera'grade lllA/l crescendo-decrescendo systolic murmur thatbegins well after th{S1 heart sound. The murmur is most notable at the lower leftsternal border. The cErotid pulsation rapidly rises.
Case 8.1Which of the following is the most likely cause of this murmur?
n*-mitral-stenosis - c\B, mitral regurgitation 3
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Case 9
A 76 year-old male presents after a syncopal episode. He is currently asymptomatic.Historically, he advises you thai he has suffered from exertional dyspnea and anginalchest pain. His blood pressure is 114196. 1. e1,ri_.
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Case 9.1 r_t C +t FWhich of the following is most likely to be discovered during his examination?
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border : sec.'r ,n^rn.,th l n"o*-fropening snap .- v,^.'k'\ S kar)-, )-E-+ridsystolic click - p1\,1p)<-
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,Selecferl Cardiovas cular Diagnostic Tools
I. Chest X-Ray (CXR) q
o Pulmonary veins - more horizontalr Pulmonary arteries - more vertical
b, Aortic coarctation. Absence of aortic knob. Rib notching (secondary to elevated intercostal arterial pressure) , . \
r Ml Consider in younger patients refractory to therapy ( <\',c' 5lur I h 1U )
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d. pericardial .tirion \- us:'\ [q \-*-Y " J.
o "water bottle " heart (not an acute chanee)^ .-^,f::=),^-^lr]l --,-- --;,. nol{lechocardiographyj confirms; quantifies fluid
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2. Exercise Electrocardiography fStress Tests]
a. assesstnent for coronary artery disease (70% sensitive detection; 75Yo specifieity exclusion)
b. various protocolsr Bruce - degree of eievation and speed changed every 3 minutes. Naughton - degree of elevation changes every 2 minutes. Echocardiogram (check for wall motion changes - hypokinesis)
c. Interpretation:o How farllong did the patient go ? [< 3 minutes - high risk]
' Symptoms ?
. EKG Changes ?** ST segment changes - horizontal or down-sloping ST segments = very suggestive CAD
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a. General usefulnessRapidly assesses cardiac silhouette and occasionally individual chamber changeso Heafi:thoracic ratio > 0.5 - cardiomegaly on upright posterior-anterior (pA) film,/ Cardiac silhouette - measured from midline to the right and to the left,/ Transthoracic diameter measured at height of right hemidiaphragm
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II. Patient Conditions
-" t' $'J [k'dt' f h ''s1. Electrocardiogram (EKG) ? i'ct
Discussed in Chest Pain and Myacardial Infarction section
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d. Perfusion Scintigraphyr Thallium-2}| (apotassiumanalog)
- Injected at peak exercise; images ASAP afterwards and at 2 - 6 hours* infarcted - "cold" spot; stays cold* Ischemic - "cold" spot; reperfuses
. Usdul: Abnormal resting EKGs (BBB); Equivocal Treadmill stress tests
. More accurate for determining extent and dislribution of ischemia
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".,c r-frH- coronary arterial anatomy- hernodynamics
b. Significant narowing - defined as at least 70% luminal narrowingr Note: 70% luminal narrowing corresponds to 50Yo reduction in cross-sectional area
c. Therapeuticstratification. Low risk - Single vessel disease (usually do well with medical therapy). High risk - Triple vessel disease (with decreased left ventricular function)
Left Main Coronary artery disease
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3. Cardiac Catheterization
a. Best test to "get the answer"
4. Ultrafast CT Scans
a. identifies coronary arterial "calcifrcation,,b. Does not visualize (quantify) all "blockage"c. Noninvasived. Role as a "Screening Test"?
B, Valvular Heart Disease
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1. Echocardiography (Transthoracic - adequate for - 90 % ofcases)a. assessment of valvular disordersb. assessment of cardiac ejection fractionsc. assessment of charnbers/wall motiond. quantifies pericardial effirsionse. Doppler echocardiography measures blood flow velocityf. assessment of ventricular thrombusg. can coupie with Exercise Electocardiography
r Transesophageal approach: rA- better views of left atrium; mitrai valve and thoracic (ascending) aorta ( PqSfCta,n
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2. Cardiac Catheterization
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C. Anltythmias
1. Electrocardiogram (EKG)
a. If patient symptomatic at the time:. may provide definitive diagnosis or rule out anhythmia
b. If done between symptomatic episodes, may provide ,,clues',:
. Long QT interval
2. Ambulatory Monitorsa. Holter Monitor - 24 hoursb, Event Recorder - days - weeks - months... ...
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.Pre.excitationsyndromes(shortPRinterval)A.,v,y\+f4/^\<i. Wolf-Parkinson-White $MpW) - delta wave pre$entii. Long-Ganong-Levine o-cl.) -no delta;;*' [
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-ong QT interval I I sVnabi
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3. Signal-Averaged EKGMonitors high-frequency, low-amplitude signal from terminal portion of QRS complexThe presence of late potentials is suggestive of a risk for ventricular anhythmias
4. Electrophysiologic (EP) Studies
Intracardiac catheters - stimulate and record cardiac events
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Valves
* Afrioventicuiar: fught - TricusPidLeft - Mitral
* Semilunar: Left - AorticRight - Pulmonic
Heart Solutds
Mechanisms:1. Valve Vibrations2. Walis of Chambers3. Vessels
Diaphraqm:
S1 (Lubb) - onset of systole (AV Valves)
52 (Dubb) - onset of diastole (SL Valves)
,-+ * solit s2\t-\-(--A2- Aortic Valve Closwe
\ Pz- Pulmonic Valve Closure
* Venticular Hyperrophy (LVH)
AUSCULTATE: (first with diaphragm' then bell)
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C\\ f S3) Vent'icular Gallop (Passive Venticular Filling)
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f;t\r,.\*.-^:#. s4-AtrialGallop(ActiveVentricularFilline) P\rrv\"'''t S 3'L'()
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C"\Aortic area (2nd right ICS, RSB)Pulmonic area (2nd left ICS, LSB) -
Second pulmonic area (3rd left ICS' LSB)Tricuspid area (4th and 5th left ICS' LSB)Apex or mitral area (5 left ICS in MCL)
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:6MURMURS
A. What ????
a. Relatively prolonged exta heart soundsb. Heard in Systole or Diastole or Bothc. Caused by turbulent blood flow into/through/out ofthe heartd. May be benign or pathologic
B. Descriptions ????
a. Timing & DurationEarly Systolic, Midsystolic (Ejection), Late SystolicEarly Diastolic, Middiastolic, Late Diastolic (Presystolic)Holosystolic (Pansystolic)Holodiastolic (Pandiastolic)Continuous
b, Intensity
Grade IGrade IIGrade IIIGrade IVGrade VGrade VI
c. Location
Jugular Venous PulsationsC4. ir.re^W: !\)ne- =B,f;- Ld(^\'t- '=
Barely AudibleQuiet, but clearly audibleModerately Loud
--.Loud and Associated witrr ffiiD- rnt r[ 6t t ( , r ' 6Very Loud, Thrill easily pu$E5t/Audible with Stethoscope not in contact with chest and thrill is visible
Auscultatory area - area ofgreatest intensity
"x" Slope: RA relaxation duringRV Systole(TV is closed)
"a" wave = right atial contraction
c" wave = closure tricuspid valvecarotid activity
'ar-' ('\2'p, J, *'*\r'icrs' S, \4
wave = venous filling(volume) of RA
"y" slope = RA emptying duringRV Diastole
(TV is open)
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Left s'*"JSYSTOLE
DIASTOLE
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aLeft-Sided Valvular Problems
Aortic Stenosis (AS)
Symptoms:
Signs:
c. If symptomatic - sugery, generally - therapy of choice
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A o rtic Re g urg it ati o n (AR)
u. Oft .fu!gg-ut!!g rdgid congenital, infl ammatory/infectiousb. Blood retums to left venticle during diastole
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a. one(gggenqln origin (bicuspid), calcific changes tn@ rheumatic feverb. Causes left ventricular outflow obstruction (during systole)
DJpryu, Angina, Syncope, Fatigue, Weakness
sro* ririnJ.-oron*.frr.. t*"r **r .t tardus;f,Diffuse left ventricular impulse 'r( *-Systolic murmur (often diamond shaped) /'Left venticular hyperlrophy )r
Symptoms: Dyspnea on exertion (DOE), Angina, SyncopePalpitations, Orthopnea/PND, Chest Pain
Signs:
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.-.d Mitrat stenosis (MS) '{: }az '..*' : 5fl,^ ,KAtf,'
)t-v .-s\.a. Often\rheurnatic in origin\more common in women (- 3F:lM)b. ElevatidTEft-atriffiGEiil. \p F
Symptoms: DyspneaiDoE, orthopneai?ND, Pulmonary edema, Angina He^t'r\" '*}T-Y--It)!r *uu\> \
Signs: ffi*' (9 [""*-)Pulmonaryhypertension/edema
(-\atrial arrhythmias ._\. - , \J
c. Medicai: Atrial fibrillation - anticoagulation and digitalis * ?' ?-^ J,^,fSurgical: Valvuloplasty, Commissurotomy, Replacement {-xr ) tn
Diastolic murmur (Often 53; occasioni
c, Ifacute - surgeryIf chronic - sugery, once symptomatic
Often 53; occasionally 54
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,$"Mitr al Re g ur g itatio n (M R)
a. Many etiologies:
kArutq infective endocarditis, chorda tendinae rupture, papillary muscle infarction...
Chronic: Blsumatic-dsease, congenital, calcification of annulus....* generally - best tolerated of valwlar iesions
P)I--Z.ZIa '{g^q \* Commofr-Sp-to T0Tlo of females ?)* Most common cause of MR* Myxomatous changes (may be part of Marfan's syndrome)* Floppy valve - Click* Barlow's syndrome - MVP + Quasicardiologic symptoms
- - 80 % of all patients may be symptomatic- nonspecific chest pain, palpitations, shorfness of breath....
b. Syrnptomatology -
Symptoms (acute): Dyspnea/PNDSymptoms (chronic): Waxing/Waning Shortness of Breath and Fatigue
Signs (acute): Pulmonary edema
Signs (chronic): LVH, Pulmonary hypertensionatrial fibrillation
c. Ifsevere - surgery
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Lesion Sy Signs Notes
UUbAnginaSyncopeOrthopnealPND
Earlv drastollc murmurD-ggssggrrdoWide oulse DressureBoundins pulses-Siffiff ;i- -"r, r
^,l'\'o L.\r
54 (occasionally)LV Heave
Louddf-> 7Cslttlngleaning forwardfull exhalation
AS DOEChest Pain (angina)Syncope
Late-peaking Systolic murmur(Pulsus parvus et tardusLV HeaveS4
\-.Loufrr", '}f--s-min-g
leaning forward
MR AcuteDyspnea, pulmonary edemaChronicWaxingAVaning dyspnea
Holosystolic murmurWide splits 52Atrial fibrillation
RadiatesAoex to axilla
DOEPND
,ll*-=. r,.r i \ C^ C
Diastolic Rumble-,,.+( ODenrns snaD-\iilaff
I-nr&+l9!-1aleraldecubitusoosition
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@turmurs of Childhood
A. Stills Murmur-_. 2-8yearsoid
. low pitched; musical quality
. systolic - grade II - III / VI .r. loudest iftuap.fiil;simfr-\ f
Deep Inspiration* Increases TR
Y Continuous - Patent Ductus Arteriosus (PDA)
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itiorir loudest - midway from low left sternal border to apexr caused by turbulent flow in left ventricular outflow
B. Venous Hum
---5yearsoldr continuous- gradel-III/VI
avicular ion; radiates i neckind or head turned
caused by turbulent flow jugular veins, as pass clavicle
Miscellaneous Murmur Notes
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2. When to worry about Childhood murmurso Loud and Harsh. Holosystolic. Diastolic 4(. Suspiciousassociation:
Loud 52GallopsCyanosisClicksAlteration in pulsesFailure to thrive
3. Murmur Characteristtcs
Diagnostic Maneuvers
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Rheumatic I{eart Disease
DefinitionAn inflammatory disease, possibly autoimmune, involving the:
Heart, joints, skin and CNS
Aschoffbody - focal, interstitial myocardial inflammation
Foliows Streptococcal infections - 7 - 35 days (mean - 18 days)
IncidenceMost common in 5 - 15 year oldsRecurrences are common, if not treated with antibiotics (- 20 %)
Clinical Presentation
Joints: Arthralgias -75%-- Migratory LL'lgl*h
Cardiac: Myocarditis, PericarditisValvular VS*MR-60-80 %;Ar-30% 0{:8, Av b\ot
Skin: Erythema marginatum < 5 7o )kSerology: Evidence of Streptococcal infection (4SO tb BUT, negative in up to 10 %)
Jones Criteria(Must have Two Major or One Major and Two Minor)
fplus evidence of Streptococcal infection, recently]
MajorS-gbgg[aneous nodules - 5 - I0 %P-olyarthritis - 75 %E-ryhqma marginatum - < 5 Yo
earditis --65%Chorea-2-3%
** Sydenham's - rare, but very diagnosticPurposeless, rapid, involuntary movementsEmotionally labile
MinorFeverArtkalgias ? !, ^ ^ , \Acute phase reactants - elevated C t \ R' ' g -ig ^t &rrc \Prolonged PR interval (increase of 0.04 seconds or more, over baseline)Previous rheumatic fever
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Infective Endocarditis
Definitionusually an infection ofthe valvular endocardium
r'--:.Valves Q.@t Aortic >> Tricuspid> Pulmonic
al: 1; MVP = , - tf Rh-eumatic Heart Disease =
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Be suspiciozts of the NEW cardiac murmur; especially in febrile patients
Special PatientsiSpecial OrganismsIDU - Staphylococcus aureus ('ricuspid valve) { ' -"-.
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Predisposing Risk
- Prosthetic Valves
- MVP* Congenital heart malformations-- Dental procedures (transient bacteremia)
Rheumatic valvular disease
IDUMiscellaneous
NOTE - Reduced risk with Secundum Atriol SePtal Defects
Classic Findine2r' gp5,\ ,.^;" )\ oodo*ri-f - ,o %) - alsoknown as:Litten's sign
ophthalmic (retinal) hemorrhages with central white spots
Osler Nodes (- 5 - 25 %)tender lesions, digital pads
Janeway Lesions (- 2 - 10 %)nontender, nonpalpable, nonblanching - violet colored
Splinter Hemorrhages (- 5 - 15 %)linear streaks subungually
Clubbing (- 10 - 50 %)
DiagnosticsTransthoracic echocardiogam - 45 - 75 %Transesophageal echocardiogram - 90 %
Blood cultures - negative in 5 - 15 % (commonly secondary to antibiotic previously prescribed or HACEK)
[Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella]
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