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Board Review Cardiology
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  1. Board Review Cardiology Karen Estrella-Ramadan

  2. Q1 • During a WCC, a 6y/o boy is noted to have a heart murmur. His parents deny any associated symptoms and report that he easily keeps us with peers during physical activity. He takes no daily medications, has no known allergies, an has never been hospitalized. His BP is 90/56 in the Right arm, HR 74 and varies with respiration. The pulses are equal and symmetric in the upper and lower extremities. As the completion of the exam the murmur is determined to be benign.

  3. Which of the following describes a benign murmur that requires no additional evaluation or follow-up? • A continuous II/VI murmur heard through systole and diastole over anterior portion of upper chest, which varies on intensity as the head is moved up and down, side to side • A harsh crescendo-decrescendo systolic murmur heard best at the apex and lower LSB, which increases in intensity with Valsalva • A harsh holosystolic murmur heard best at the lower LSB • A systolic ejection murmur heard best over the 1st and 2nd left intercostal spaces associated with a widely split and fixed 2nd heart sounds • An ejection click heard best at the LUSB inmediately following the 1st heart sound during expiration 10 Countdown

  4. A continuous II/VI murmur heard through systole and diastole over anterior portion of upper chest, which varies on intensity as the head is moved up and down, side to side • Venous hum: turbulent flow in yugular vein • A harsh crescendo-decrescendo systolic murmur heard best at the apex and lower LSB, which increases in intensity with Valsalva • Hypertrophic cardiomyopathy • A harsh holosystolic murmur heard best at the lower LSB • VSD • A systolic ejection murmur heard best over the 1st and 2nd left intercostal spaces associated with a widely split and fixed 2nd heart sounds • ASD • An ejection click heard best at the LUSB inmediately following the 1st heart sound during expiration • PS

  5. Q2Which of the following require antimicrobial prophylaxis prior to the procedure in a 12y/o boy with a prosthetic heart valve? • Adjustment of orthodontic appliances • Endotracheal intubation • Tonsillectomy • Inguinal hernia repair • Cystoscopy 10 Countdown

  6. C • Endocarditis prophylaxis ONLY FOR PTS WITH: • a prosthetic heart valve • Hx of previous endocarditis • Hx of complicated unrepaired cyanotic congenital heart disease, or s systemic to pulmonar artery shunt or conduit • Repair of congenital heart defect with prosthetic material < 6months ago • Residual defects following repair of a congenital heart lesion • Procedures that require prophylaxis • Tooth extraction • Tonsillectomy/ adenoidectomy • Dental implants • Periodontal or endodontal procedures • Surgical procedures involving the respiratory mucosa • GIVE AMOXICILLIN 50MG/KG max 2gr, 1 HR PRIOR

  7. NO NEED FOR PROFILAXIS: • Kawasaki disease • RF without valve dysfunction • Pacemaker • Implantable defibrillator

  8. Q3During his PE following d/c from the normal nursery, a 7day old boy is noted to have a II/VI medium-pitched ejection murmur heard best at the LUSB, which radiates well to the posterior lung fields and axillae.Which of the following is the most likely etiology for this pt’s findings? • Pulmonary flow murmur • Venous hum • Peripheral pulmonary stenosis • Vibratory (still) murmur • VSD 10 Countdown

  9. PPS • Common in newborns, resolved by 2-3 months • II/VI systolic murmur best on LUSB, radiating to posterior lung fields and axillae • Due to turbulent flow at the origin of the small branch pulmonary arteries as they exit the large main pulmonary artery • Pulmonary flow: systolic ejection murmur best in LUSB • turbulant flow where main pulmonary artery connects with RV • Vibratory or “still” murmur: II/VI mid systolic murmur heard best on LLSB and apex • blood flow in the LV that leads to vibrations in the ventricle or mitral structure • toddlers, school age

  10. Q4A chronically ill 12y/o M with Crohn disease presents to the ER with rectal bleeding. His Hb is 5.7. On PE, his HR is 140. A prominent, low-pitched extra heart sound is noted in early diastole.Which of the following is the likely cause of this auscultatory findings? • Blood entering a stiff, poorly compliant L ventricle during atrial contraction • Blood from the LA rushing into an already overfilled failing ventricle • An opening snap (abrupt recoil) of a stenotic mitral valve • A moderate amount of pericardial fluid • Prolapse of the mitral valve leaflets 10 Countdown

  11. Blood entering a stiff, poorly compliant L ventricle during atrial contraction • S4 rare in kids, better when pt supine or L lateral • Blood from the LA rushing into an already overfilled failing ventricle • S3 • during diastole ventricle fills up in 2 phases: early passive blood flow from atria  vibration of ventricular walls and later a vigorous atrial ejection • HTN or severe anemia • Heard best with bell with pt on L lateral recumbent position • An opening snap (abrupt recoil) of a stenotic mitral valve • A moderate amount of pericardial fluid • Prolapse of the mitral valve leaflets • Apical systolic murmur associated with a mid-systolic apical click • Anorexic bradycardia, weak irregular pulses and hypotension

  12. Q5A 1wk old boy is noted to have a heart murmur during his first outpatient visit following discharge from the newborn nursery at 48hrs of life.Which of the following best describes the most common congenital heart lesion? • A harsh holosystolic murmur heard best at the LLSB • A systolic ejection murmur and a widely split and fixed 2nd heart sound • A machine-like continuous murmur heard throughout systole and diastole • A nonspecific ejection murmur at the heart apex associated with decreased femoral pulses • A loud systolic ejection murmur in the LUSB associated with evidence of RV hypertrophy 10 Countdown

  13. A harsh holosystolic murmur heard best at the LLSB • VSD • A systolic ejection murmur and a widely split and fixed 2nd heart sound • ASD • A machine-like continuous murmur heard throughout systole and diastole • PDA • Best on left 2ndintercostal space, wide pulse pressure and bounding pulses • A nonspecific ejection murmur at the heart apex associated with decreased femoral pulses • Coartation of aorta • A loud systolic ejection murmur in the LUSB associated with evidence of RV hypertrophy • TOF

  14. Frequency of cardiac defects • VSD ASD coartation of aorta PDA TOFpulmonary valve stenosis aortic valve stenosis transposition of the great arteries hypoplastic LV For Boards: Baby 3-4wks old coming with signs of shock, r/o VSD as cause of CHF

  15. Q6A 3hr-old boy is noted to be cyanotic with a RR:88. A parasternal heave is noted during cardiac examination, as is a single loud 2nd heart sound and a soft systolic ejection murmur at the mid-LSB. An echo reveals that the pulmonary artery arises from the LV and the aorta arises from the morphologic RV.Which of the following best describes expected findings on a CXR in pts with this disorder? • A narrow mediastinum associated with mild cardiomegaly • Marked cardiomegaly associated with increased pulmonary vascularity • Normal heart size with decreased vascular markings • Decreased vascular markings associated with a “boot-shaped” heart • Pulmonary edema associated with cardiac enlargement 10 Countdown

  16. Transposition of the great vessels A narrow mediastinum associated with mild cardiomegaly

  17. Truncusarteriosus Marked cardiomegaly associated with increased pulmonary vascularity

  18. Tricuspid atresia Normal heart size with decreased vascular markings

  19. TA repair • Stage OneBlalock-Taussig (BT) shunt: first few days after birth, and establishes a systemic-to-pulmonary artery shunt between the brachiocephalic artery or the right subclavian artery, to the right pulmonary artery via (usually) a tubed homograft or synthetic graft.Glenn Procedure or Hemi-Fontan: usually performed at 4-6 months after birth as a bridge to Fontan completion. The BT shunt and pulmonary artery band is usually removed. The superior vena cava is then attached to right pulmonary artery, creating a systemic venous-to-pulmonary connection.Fontan Completion: Usually performed at 2-3 years of age; the inferior vena cava is connected to the right pulmonary artery via a tunnel like patch within the right atrium (Lateral Tunnel Fontan), or by creating a conduit for IVC flow outside the right atrium (ExtracardiacFontan).

  20. Tetralogy of Fallot Decreased vascular markings associated with a “boot-shaped” heart

  21. Hypoplastic left heart syndrome Pulmonary edema associated with cardiac enlargement

  22. TAPVR

  23. Coartation of Aorta

  24. Q7A 17y/o F complains of decreased exercise tolerance over preceding several months. She is especially concerned because she has always been an outstanding athlete. She has no known history of any chronic medical problems and takes no daily medications.Which of the following clinical findings is most often associated with a congenital heart lesion that often does not become symptomatic until the 2nd decade of life? • A fixed split 2nd heart sound • A harsh, high-pitched holosystolic murmur well localized along the LSB • A harsh continuous murmur heard best in the 1st and 2nd L intercostal spaces • A systolic ejection murmur associated with a systolic click along the LSB • A continuous murmur throughout both systole and diastole heard best in the 1st and 2nd R intercostal spaces, which varies in intensity when the position of he neck changes 10 Countdown

  25. ASD • Exercise intolerance in the 2-3rd decade • LR shunting increases

  26. Q8While running sprints during conditioning exercises for soccer, a 17y/o F suddenly collapses. Her coach reports that she “woke up after 30-45 sec” and was immediately oriented and appeared in NAD. Upon arrival to the ER, her VS are stable. PE is unremarkable. She takes no daily meds and denies chronic medical problems. Utox is neg. an ECG reveals a RBBB and ST-segment elevation in lead V1-V3.Which of the following is the most likely cause of syncope in this patient? • Hypertrophic cardiomyopathy • Anomalous L coronary artery • WPW • Brugada syndrome • Primary pulmonary HTN 10 Countdown

  27. Brugada syndrome • Associated with syncope during exercise and sudden unexpected cardiac death. • RBBB and ST segment elevation in leads V1-V3 • Autosomal dominant with variable expression • Due to defect in myocardial sodium channels • Risk of both ventricular and tachyarrythmias • Tx: implantable cardioverter-defibrillator

  28. ECG characteristics • Hypertrophic cardiomyopathy: • LV hypertrophy and variable ST-segment depression with T wave inversion • Anomalous L coronary artery: • ~lateral MI with large and wide Q waves in leads I, V5, V6; ST elevation in V5, V6 and T wave inversion in V6. • WPW: • short PR interval, delta waves and wide QRS • Primary pulmonary HTN: • RV hypertrphy associated with spiked P waves

  29. Remember