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USMLE1 01

Cardiology 1

QuestionAnswer
what is pheochromocytoma? tumors of the adrenal gland --> excess adrenaline
congenital defects such as uni/bicuspid aortic valve causes what? aortic stenosis
L ventricular hypertrophy - aortic insuff or stenosis? either/both
crescendo decrescendo murmur aortic stenosis
tardus et parvus aortic stenosis. also pulsus parvus et tardus, slow-rising pulse and anacrotic pulse, where upon palpation, the pulse is weak/small (parvus), and late (tardus) relative to its usually expected character.
L ventricular dilation- aortic insuff or stenosis? aortic insuff due to increased preload
how do you tell the difference between chronic and acute aortic insufficiency? chronic - dilation of L ventricle; acute - pulmonary edema because everything is backed up into the lungs
wide pulse pressure aortic insufficiency
water-hammer pulse aortic insufficiency
Austin Flint rumble aortic insufficiency
diastolic and systolic murmur aortic insufficiency
caused by rheumatic heart disease mitral stenosis
L atrial hypertrophy and dilation mitral stenosis
systolic murmur mitral insuff or aortic stenosis
diastolic murmur mitral stenosis or aortic insuff
jugular venous distension think mitral stenosis
prominent a wave greater pressures in atrial contraction - mitral stenosis
RV hypertrophy mitral stenosis
L atrial enlargement and L ventricular dilation mitral insufficiency
increased preload and decreased cardiac output mitral insufficiency
very high v-wave mitral insufficiency due to increased volumes in both LA and LV
c wave ventricular contraction that closes the mitral and tricuspid valves
holosystolic mumur mitral insufficiency
mid-systolic click mitral valve prolapse in mitral insufficiency
Patient has systolic ejection murmur in the R second intercostal space, which radiates into the carotids; S4 heart sound, which increases in intensity on expiration, prominent PMI. What does the person have? aortic stenosis
What side of the patient should you evaluate a jugular venous pulse? R side because that's the R side of the heart where you can see the blood backing up into the jugular vein
c-wave venous P marks beg of systole: vent contract --> pulmonary and aortic valves open, tricuspid and mitral valves close --> blood in RV pushes up against the closed tricuspid valve --> increase pressure in R jugular vein; corresponds with the S1 heart sound
a-wave venous P at end of diastole: atria contract --> squeezes blood into vent --> pulm & aortic valves close, tricuspid n mitral valves open --> blood in SVC backs up into jugular --> increase pressure in R jugular vein; corresponds with the S4 heart sound
v-wave the atria filling up during ventricular contraction (systole); peaks at the end of systole, right before the atria contract again
What happens to the venous trace when you have tricuspid stenosis? giant a-wave due to increase pressure in atria (and therefore greater pressure backup into the jugular) during atrial contraction
What happens to the venous trace when you have tricuspid insufficiency? giant c-wave n v-wave. Insufficiency --> during vent contr --> blood pushed back into the atria (bigger c-wave). At the end of systole, the R atrium has all the blood from the vena cava, PLUS the blood pushed up from the RV as well --> bigger v-wave.
S1 beginning of systole: ventricles contracts --> pulmonary and aortic valves open, tricuspid and mitral valves close, corresponds to the c-wave in the venous trace. Indicates MITRAL STENOSIS (mitral leaflets so hard they crunch together when they close).
S2 end of systole --> aortic n pulm valves close. Resp variation w inspir due to diaphragm down --> blood sucked INTO the right heart --> pulm valve closes later than aortic on inspiration (p2 separates from a2 on inspiration and comes back on expiration).
S3 Ventr "gallop" -- like paper bag. Dilated heart or volume overload. Can be nl in someone <35 yo, but older than that, is prob pathologic. Early diastole --> atria pump blood into dilated/volume overloaded ventricular chambers --> turbulent sound S3.
S4 Atrial "gallop". Late diastole. Snd of atrial contr against inc resistnc -- no give when atria push bld into vent. Ao STENOSIS (LV hypertr due to inc afterload), hypertr vent, or already overfilled chamber. Problem w compliance (ability to fill up).
In HTN, which abnormal heart sound would you have? S4 because of increased afterload --> hypertrophied ventricles --> atrial gallop.
How to tell if abnormal heart sounds are due to R sided or L sided heart problem? If a R hrt prob, incr intens with insp. Dphrgm down --> neg P in pleural cavity, bld sucked into R --> inc vol in R side --> hrt snds ldr. If L sided prob, inc in intns w expr. Brthe out --> LV get mr bld to aorta --> L hrt snds louder whn brthe out.
Which side of the heart is the problem on? Essential HTN L
Which side of the heart is the problem on? Mitral regurg R. Inc preload --> dec LV contractility --> LV failure --> pulmonary edema --> pulmonary HTN --> RV failure, holosystolic murmur, s3 (paper bag, LV dilation) gallop.
Which side of the heart is the problem on? Mitral stenosis R. Inc vol in LA --> pulm edema --> pulm HTN --> RV failure, diast murmur. Loud S1 bc increased volume slams the mitral valve shut at the beginning of systole. S2 with opening snap because the mitral valve opens late at the beginning of diastole.
Valvular stenOsis problem with Opening the valve
Valvular regurgitation problem when valve is closing
Opening in systole: systolic murmur Aortic and pulmonic stenosis, crescendo-decrescendo. Diamond shaped, ejection murmur.
Closing in systole: systolic murmur Mitral and tricuspid insufficiency, holosystolic
Opening diastole: diastolic murmur Mitral and tricuspid stenOsis
Closing in diastole: systolic murmur Aortic and pulmonic insufficiency
Where to hear aortic valve best R second intercostal space
Where to hear pulmonic valve best L second intercostal space
Where to hear mitral valve best apex
Where to hear tricuspid valve best L parasternal border
Aortic stenosis Systolic ejection murmur, crescendo-decrescendo, intensity increases on expiration, heard best in the R 2nd intercostal space, radiates to the carotids, S4 (hypertrophied LV due to increased afterload)
Pulmonic stenosis Systolic ejection murmur, crescendo-decrescendo, intensity increases on inspiration, heard best in the L 2nd intercostal space, radiates to the carotids, S4
Mitral stenosis Diast murm, mid-diast rumble, intens inc on exp, best at apex, S1 (mitral is so hard it crunches togthr) w openg snap (mitral opens late bc so inflex). Prob w LA - dilated n hypertr. Predisp to afib, stasis, thromb. LA can't fill LV, so no hypertr!
Tricuspid stenosis Diast murm, mid-diast rumble, inc on insp, best at L parasternal brdr, S1 (tricusp so hard it crunches togthr) w openg snap (tricusp opens late bc so inflex). Prob w RA-dilat n hypertr. Predisp to afib, stasis, thromb. RA can't fill RV, so no hypertr!
Aortic insufficiency LV dilat, vol overload --> inc contr (LV hypertrophy), water-hammer pulse (inc systolic because of inc force of contration, but dec diastolic because blood leaking back into heart and less in systemic circulation during diastole)
Early diast murm (rt after S2): high-pitched, blowing at L stern brdr. Aortic Insufficiency
Mitral insufficiency Holosystolic murmur (blood flows back up into the LA), sometimes obliterating S1 S2, LV dilation, heard best at the apex, hear S3 (LV dilation, paper bag, problem with compliance of LV) and S4 (volume overloading LV), increases in intensity on expiration
Tricuspid insufficiency Holosystolic murm (bld flows back up into the RA), sometimes obliterating S1 S2, RV dilation, heard best at the L parasternal brdr, hear S3 (RV dilation, paper bag, problem with compliance of RV) and S4 (volume overloading RV), inc intensity on insp
IV drug abuser with fever, holosystolic murmur on parasternal border, S3, S4, accentuation of neck veins, murmur increased on inspiration Tricuspid insufficiency, infective endocarditis of tricuspid valve
What does it mean clinically when you hear an Austin-Flint rumble Aortic insufficiency --> blood dripping back into LV and hitting anterial leaflet of mitral valve. The valve needs to be replaced surgically because there is significant malfunction of the aortic valve.
Systolic click-murmur-click-murmur Mitral valve prolapse: blood from LV pushes prolapsed valve into the LA – hear a click once it’s done parachuting out, then the murmur is the blood getting into the LA due to the regurg (not closing properly)
Is the click-murmur-click-murmur of mitral valve prolapse closer to S1 or S2? Depends on the preload. If increased preload (lying down), the murmur is closer to S2. If decreased preload, the murmur is closer to S1 (tachycardia, standing up).
What causes mitral valve prolapse? excess production of the glycosaminoglycan, dermatan sulfate --> excess myxomatous degeneration of mitral valve leaflet
What genetic diseases are associated with mitral valve prolapse? 1. Marfan's (defect in fibrillin), 2. Ehler Danlos (defect in collagen)
A Marfan's patient dies suddenly. What is the most likely cause? Mitral valve prolapse with conduction defects. Not an aortic dissection because you don’t die suddenly with dissection. You’d have pain, radiation, cardiac tamponade.
List organs that HTN affects: 1. heart (MI), 2. stroke, 3. renal failure
Essential HTN in what racial group is highest? What is the inheritance pattern? Blacks - highest HTN group, multifactorial inheritance. Can't get rid of salt in the urine.
In what age group is essential HTN highest? Elderly
Inheritance pattern for CAD multifactorial inheritance - tendency for, but not necessarily get the disease
Inheritance pattern for gout multifactorial inheritance - tendency for, but not necessarily get the disease
If predisposed to gout due to family hx, how to avoid getting gout? no red meats, no EtOH (dec purine metab)
Inheritance pattern for Type II DM multifactorial inheritance - tendency for, but not necessarily get the disease
If predisposed to Type II DM due to family hx, how to avoid getting DM? weight control, lose adipose --> upregulate insulin receptor synthesis
Inheritance pattern for affective disorders multifactorial inheritance - tendency for, but not necessarily get the disease
Inheritance pattern for congenital pyloric stenosis multifactorial inheritance - tendency for, but not necessarily get the disease
If predisposed to HTN due to family hx, how to avoid getting HTN? Control weight, reduce salt intake, exercise.
Mechanism for HTN in blacks and elderly Can't pee out salt --> salt retained in ECF --> inc plama vol --> inc stroke vol --> inc SBP. Na goes into smooth muscle of arterioles --> Na opens channels for Ca entry --> smooth muscle contraction --> contraction of arterioles --> inc diastolic BP.
What is the treatment of choice of HTN for blacks and elderly? hydrochlorothiazides --> pee out salt and water --> dec BP
If a pt has HTN + hyperlipidemia, which medications should they avoid? HTN meds: hydrochlorothiazides and β-blockers because these drugs can produce hyperlipidemia. These patients must use ACEi's.
Is HTN due to salt retention have high or low levels of renin? Low. Salt retention --> inc plasma vol --> inc renal blood flow --> dec renin release.
What is the most common location in the brain for bleeds due to HTN? globus pallidus/putamen area --> stroke. Bc lenticulostriate vessels frm MCA, under inc P, form aneurysms (Charcot-Bouchard aneurysm) --> rupture. This is hematoma, not infarct. If a Charcot-Bouchard aneurysm ruptures, it will lead to an intracerebral
Pt with HTN experiences sudden focal paralysis or loss of sensation the lenticulostriate vessels from the MCA (middle cerebral artery), under increased pressure, form aneurysms (Charcot-Bouchard aneurysm) --> rupture. This is a hematoma, not an infarct. If a Charcot-Bouchard aneurysm ruptures, it will lead to an intrace
Sx's of subarachnoid hemorrhage saccular (berry aneurysm) aneurysm ruptures, it will lead to a subarachnoid hemorrhage, typically experienced as an extremely severe headache leading to loss of consciousness
Increased afterload produces what kind of hypertrophy? Concentric. Thick hypertrophy. Increased afterload requires more work and can be caused by things like stenotic aortic valve & increased TPR from HTN.
Increased preload produces what kind of hypertrophy? Dilated & hypertrophied. Valvular problem (e.g. aortic insufficiency) --> excess volume of blood in ventricles --> inc preload. Starling --> increase preload --> inc force of contraction --> dilatation & hypertrophy.
Heart sounds correspond with what? valves closing
What is the most common cause of sycope and angina with exercise? Aortic stenosis. More difficult to push blood out against stenotic aortic valve --> stroke volume diminished --> Pulse diminished. Coronary arteries filled up in diastole --> if decreased stroke volume --> less blood to heart (causes angina with exercis
What is the most common cause of microangiopathic hemolytic anemia? Aortic stenosis.
Ejection type murmur, R second intercostal space, radiation into the neck, increases in intensity on expiration. What is wrong with the patient? Aortic stenosis
Listening to a murmur, how do you determine if it's aortic stenosis or hypertrophic cardiomyopathy? Aortic stenosis: murmur gets louder with increased preload (more blood to push out, more noise getting it through the stenotic orifice) and softer with decreased preload. Hypertrophic cardiomyopathy (problem is blood flow pulls mitral valve leaflet again
Patient comes in with hoarseness, dysphagia for solids, not liquids, a irregularly regular pulse, and a diastolic murmur: snap then rumble, best heard at apex, increase in intensity in expiration Mitral stenosis. Hoarseness because the LA dilation stretches the left recurrent laryngeal nerve, the dysphagia is from the dilated LA pressing on the esophagus, the murmur is of mitral stenosis, irregularly regular pulse is atrial fibrillation
How would a patient with mitral valve stenosis experience dysphagia for solids? Mitral stenosis --> dilated LA --> press on esophagus
Austin-Flint rumble Ao insuff. Late diast murm: Austin Flint rumble at apex (whn bld drips back into LV due to aortic insuff --> hits anterior leaf of mitral).
Created by: christinapham