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teaching and examinations
 
 

1.     70 yrs, male, recent stroke 3 wks with mild residual hemipharesis. On warfarin for A.Fib. Patient is diaphoretic, dyspneic, Hypotensive (70 systolic BP), crackles, +JVD.

     ECG show: complete heart block, LBBB with acute inferoposterior current of injury. Management?

 

1. Monitor

2. Establish IV access

3. Send CBC, Electrolytes, Creatinine, Urea, INR, PTT

4. ASA

5. IV Heparin

6. Temporary pacer if still hypotensive

7. PA catheter insertion

8. IV fluid bolus, if still hypotensives Inotropes

9. Arrange for cardiac catherization

 

 

 

2.     Patient with aortic coarctation and bicuspid aortic valve. What complications over the next 20 yrs?

 

                                                              i.      Increased progression of aortic stenosis.

                                                            ii.      Risk of infective endocarditis

                                                          iii.      May develop aortic reguirgitation

                                                          iv.      Aneurysmal aortic root dilatation

                                                            v.      Possible aortic dissection/rupture

                                                          vi.      Most patient with coarctation develop systemic hypertension

                                                        vii.      Increased risk of premature coronary artery disease

                                                      viii.      Cerebral hemorrhage

 

3-  .Patient with prosthetic aortic valve with fever and costitutional symptoms. Echo 6 months ago was normal. Echo show aortic vegetation. Blood cultures drawn within 24 hrs are negative.

a.     Reasons for negative Blood cultures.

b.    Management.

c.      ECG shown – complete heart block with junctional escape. What is the management now?

 

 

 

 

a. If antibiotics have not been administered prior to obtaining blood cultures, the causes are

fastidious organisms (slow growing)

 

HACEK organisms (Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella species, and Kingella species).

Legionella species

Bartonella species

Coxiella burnetii

Mycoplasma hominis,

Fungal

 

a.       In the absence of clinical clues to a specific etiology, therapy for culture-negative PVE should include at least vancomycin and gentamicin. For patients with the onset of disease 12 months or more after valve implantation, ceftriaxone or cefotaxime should be added to this regimen in order to effectively treat HACEK PVE.

 

                      c. Surgery

 

4- Describe the auscultatory findings in

a.     Austin Flint

b.    Carey Coombs

c.      Graham Steele

 

  1. Austin Flint

- Mid-diastolic rumble with presystolic accentuation from rapid antegrade flow across MV that is narrowed by rapid rise in End Diastolic Pressure

- Caused by mitral inflow turbulence cause by AR jet

- Decrease with Amyl nitrate, while MS murmur increases with amyl nitrate

 

  1. Carey Coombs murmur

- Soft early diastolic murmur. Higher pitch than MS murmur

- Sign of active mitral valvulitis with rheumatic fever

 

  1. Graham Steele

- Early diastolic high frequency blowing murmur begins after P2 that may last throughout diastole

- Pulmonary reguirg secondary to pulmonary hypertension

 

 

5-    35 yrs old female pregnant, 2nd trimester known MS presents with SOB and BP 70, atrial fibrillation and rapid HR

d.    Initial therapy

e.      Post cardioversion what meds can you use to take control of heart rate chronically.

f.      Obstretrician asks about using ACE-I

g.     Echo done and MVA 0.9 cm2, has signs and symptoms, what can you do.

h.    Plan to do angiogram, what precautions are required

 

a.         - Electrical synchronized cardioversion

            - Admit

            - Anticoagulate with IV heparin

b.         β-Blockers/Digoxin

c.         ACE-I are contraindicated during pregnancy

-          Prolonged fetal hypotension & death

-          Inceased risk of early delivery, low birth wt, oligohydramnios, neonatal anuria & renal failure

d.         If the valve anatomy is favorable {by Boston grading system, the components are (by Mobility, Subvalvular thickening, Thickening of leaflets, & Calcification)} in the absence of significant MR or Lt atrial thrombus, then would consider percutaneous balloon mitral valvuloplasty

e.         Shielding of the abdomen (??? Check answer)

            Short flouro time

            Performed by experts

 

 

 

 

 

 30 year-old female elementary school teacher with history of rheumatic fever age 10 and was treated with antibiotic prophylaxis until age 20.  She has a 3 year-old son with a strep throat.  Asymptomatic and has a grade 2/6 holosystolic murmur.

- What therapy should she be on (include dose)?  Should she take rheumatic fever prophylaxis?

- If allergic to penicillin, then what?

- For how long?

 

Yes, she should be on rheumatic fever prophylaxis and endocarditis prophylaxis.  She has had documented rheumatic fever with residual valve disease.  She should be on RF prophylaxis at least until age 40 or possibly longer given that she has a young child. 

 

 

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