Dr. Nine Heart Path Cases

Front 1

45yr old black man with HTN
No medical history, no meds
Family history of HTN

Back 1

Essential/primary HTN
(no cause)
90-95% of HTN cases

Front 2

54yr old white man with Conn Syndrome (hyperaldosteronism) and HTN

Back 2

Secondary HTN (has a cause)
-Adrenal cortical hyperplasia or adenoma

Front 3

67 yr old white man with severe atherosclerosis has cardiomegaly with LV hypertrophy

Back 3

Cardiovascular cause of secondary HTN
-atherosclerosis= rigid aorta

Front 4

51 yr old woman with HTN and renal artery stenosis

Back 4

Secondary HTN; Goldblatt kidney
-atherosclerosis or fibromuscular dysplasia

Front 5

51yr old woman with HTN and renal artery stenosis.
No history of atherosclerosis or other vascular dz

Back 5

Secondary HTN; Goldblatt kidney caused by fibromuscular dysplasia

Front 6

67yr old woman with HTN and hyperaldosteronism

Back 6

Secondary HTN; due to Conn syndrome (adrenal cortex hyperplasia or adenoma)

Front 7

A patient with cardiomegaly with LV hypertrophy

Back 7

First I think HTN, then other causes:
-aortic stenosis
-hypertrophic cardiomyopathy

Front 8

78yr old man, sudden death
Autopsy shows granular contracted kidney
(microscopic findings?)

Back 8

-Hyperplastic arteriolarsclerosis,
-sclerotic glomeruli (ischemic damage)
-benign chronic HTN

Front 9

59yr old man, sudden death
-autopsy showed "flea-bitten" kidneys and cerebral hemorrhage infarct (stroke)

Back 9

Hypertensive crisis, malignant HTN
-pinpoint hemorrhages over granular surface

Front 10

68yr old man with diabetes mellitus (type 2) now has peripheral vascular disease

Back 10

-atherosclerosis (atheromatous plaques)

Front 11

61yr old woman with essential HTN, inc BUN and creatinine (developing sings of renal insufficiency)

Back 11

-arteriosclerosis (hyperplastic=malignant or hyaline=benign)

Front 12

56yr old man found to have calcification of his radial artery during an x-ray for a forearm injury. No vascular symptoms

Back 12

-Monckeberg medial sclerosis (AKA medial calcific sclerosis)

Front 13

70yr old woman with systemic atherosclerosis and "carotid bruit" now has symptoms of a cerebral infarct (stroke)

Back 13

-embolism (form carotid atheroma)

Front 14

74yr old man with pulsatile abdominal mass on physical exam suddenly becomes hypotensive and develops hemodynamic collapse

Back 14

-ruptured aortic aneurysm

Front 15

68yr old woman w essential HTN experiences sudden onset of excruciating chest pain radiating to themiddleof her back. she collapses and becomes unresponsive

Back 15

-dissection of thoracic aorta
-hemopericardium?

Front 16

35yr old man w Marfan's syndrome experiences sudden onset of excruciating chest pain radiating to the middle of his back

Back 16

-dissection of thoracic aorta
-cystic medial degeneration (or necrosis)

Front 17

43yr old man w recent recurring low-grade headache experiences the "worst headache of his life" then suddenly collapses

Back 17

-rupture of cerebral berry aneurysm
-recent leakage

Front 18

69yr old woman w stage IV cancer of the R lung experiences gradual swelling and edema of her R arm, jugular venous distention and capillary congestion of her head and neck

Back 18

-Superior vena cava syndrome

Front 19

A 60yr old man with acute posterior wall MI
-which vessel was involved?

Back 19

-Right coronary artery (75%); could be Left circumflex (if it was a left dominant system)

Front 20

A 60yr old man with acute anterior wall MI
-which vessel was involved?

Back 20

-Left anterior descending (most common one)

Front 21

A 60yr old man with acute anterior wall MI
-What is the vessel pathology that is involved?

Back 21

-Vulnerable plaque (acute)
-hemorrhage, thrombosis, rupture

Front 22

A 75yr old woman with acute anterior wall MI that happened 12hrs ago
What do you expect to see in the myocardium?

Back 22

-Nothing or coagulative necrosis
(contraction bands)

Front 23

A 75yr old woman with acute anterior wall MI that happened 2 days ago.
What do you expect to see in the myocardium?

Back 23

-Neutrophils, cellular debris

Front 24

A 68yr old woman with acute anterior wall MI that happened 5 days ago.
-what is the most concerning risk at this point?

Back 24

-Ventricular rupture with hemopericardium
(stage in which there isn't much structural component of myocardium left)

Front 25

A 52yr old man with acute posterior wall and septal MI that happened 4 days ago. Now has acute mitral valve insufficiency.
-what is the problem?

Back 25

-Papillary muscle rupture

Front 26

58yr old man had CABG surgery 5 days ago. Now has chest pain and friction rub?

Back 26

Dressler's syndrome, pericarditis

Front 27

79yr old woman with large lateral wall MI 6 months ago. Has ischemic stroke.
What complication?

Back 27

-Mural thrombus

Front 28

53yr old man dies suddenly at home. Autopsy only shows LAD with 95% proximal stenosis.
-what happened?

Back 28

-Sudden cardiac death; fatal arrhythmia

Front 29

38 yr old woman with "chest fluttering". You hear a mid-systolic click with late systolic murmur?

Back 29

-mitral valve prolapse

Front 30

53yr old man with a diastolic murmur. Has history of rheumatic fever as a child?

Back 30

-mitral valve stenosis- rheumatic heart disease

Front 31

53yr old man with holosystolic murmur. Has history of rheumatic fever as a child?

Back 31

-mitral valve insufficiency and regurgitation - rheumatic heart disease

Front 32

78yr old man with systolic murmur. EKG shows left ventricular hypertrophy?

Back 32

-Aortic stenosis- calcific degenerative

Front 33

48yr old man with systolic murmur. EKG shows LV hypertrophy?

Back 33

-Aortic stenosis- bicuspid aortic valve

Front 34

48yr old man with history of systolic murmur. Now presents with sudden onset of severe "tearing" chest pain radiating to back?

Back 34

-Aortic dissection- bicuspid aortic valve with stenosis

Front 35

6yr old with 4-day history of "sore throat" and rash. Did not go to doctor. Collapses suddenly. Autopsy shows myocarditis?

Back 35

-Rheumatic heart disease- myocarditis and sudden death

Front 36

56yr old woman with Lupus. Sudden onset of stroke symptoms

Back 36

-endocarditis- Libman Sacks, embolic event
-thrombus can flick off

Front 37

58yr old man with terminal head and neck cancer. Sudden onset of stroke symptoms?

Back 37

-endocarditis- non-bacterial thrombotic endocarditis- embolic event

Front 38

38yr old chronic IV drug abuser. Osler node on right index finger, splinter hemorrhages?

Back 38

-Endocarditis- infectious bacterial
-in this case= tricuspid valve
(pseudomonas, staph. aureus)

Front 39

5yr old with "sore throat" for 5 days collapses suddenly. Heart sounds are distant, JVD, hypotension. Therapeutic intervention?

Back 39

-Pericarditis with cardiac tamponade= pericardiocentesis
"Beck's triad"
[beck played JV in HS]

Front 40

65yr old woman with chronic renal failure. Sudden onset of chest pain. Exam shows friction rub.

Back 40

-fibrinous pericarditis= uremia

Front 41

56yr old alcoholic pneumonia and sepsis. Acute substernal chest pain. Exam shows friction rub?

Back 41

-Purulent (suppurative) pericarditis infection

Front 42

68yr old woman with advanced untreatable lung cancer. Now has signs and symptoms of pericarditis.

Back 42

-hemorrhagic pericarditis- tumor invasion

Front 43

54yr old with recent CABG surgery. Sharp substernal chest pain and hypotension

Back 43

-Fibrinous pericarditis= post-pericardotomy syndrome
-coronary artery bypass graft surgery, "Dressler's syndrome"

Front 44

32yr old Chilean. Develops cardiac abnormalities 10wks after trypanosoma cruzi infection

Back 44

-Myocarditis- American trypanosomiasis, Chagas dz
(eosinophilic)
-chronic incurable

Front 45

25yr old male dies suddenly in 3rd day of an influenza infection

Back 45

-Myocarditis- infectious, influenza virus

Front 46

57yr old woman receiving chemotherapy for breast cancer. Sudden new onset cardiac arrhythmias. Myocardial biopsy shows eosinophilic infiltrate

Back 46

-Hypersensitivity myocarditis= chemotherapy, antibiotics

Front 47

11yr old suddenly dies after 36hr course of apparent viral infection. Heart exam shows myocarditis with giant cells

Back 47

-Giant cell myocarditis- unique aggressive form in younger patients

Front 48

Anyone with suspected myocarditis
-Diagnostic requirements?

Back 48

-Inflammatory infiltrate
-myocyte damage or necrosis

Front 49

18yr old heart transplant recipient. Signs of rejection. Biopsy shows myocardial inflammation and myocyte necrosis

Back 49

-Acute transplant rejection

Front 50

18yr old heart transplant recipient. Signs of rejection. Biopsy shows fibroproliferative coronary artery narrowing (of intima)

Back 50

-Chronic transplant rejection

Front 51

78yr old man with chornic benign hypertension now has symptoms of pulmonary edema (shortness of breath, cough, frothy sputum)

Back 51

-LEFT heart failure- caused by systemic vascular disease (HTN)

Front 52

78yr old man with chronic benign HTN now has ascites and lower extremity edema

Back 52

-RIGHT heart failure- caused by LEFT heart failure

Front 53

78yr old man with chronic emphysema now has ascites and lower extremity edema

Back 53

-RIGHT heart failure- caused by pulmonary disease (COR PULMONALE)

Front 54

56yr old chronic alcoholic presents with congestive heart failure and has a large cardiac silhouette on chest X-ray

Back 54

-Dilated cardiomyopathy- most often idiopathic, can have other associations

Front 55

28yr old dies suddenly with no known pre-existing conditions. Autopsy shows 950g heart with massive LV hypertrophy

Back 55

-hypertrophic cardiomyopathy-genetic cause

Front 56

78yr old man presents with signs of heart failure. Evaluation and biopsy show amorphous material in myocardium with "apple-green birefringence".

Back 56

-Restrictive cardiomyopathy- amyloid deposition "amyloid heart dz"

Front 57

5mo old infant dies suddenly while sleeping. Autopsy shows dense fibrosis of LV endocardium

Back 57

-endocardial fibroelastosis= unique and rare cause of sudden death in infants

Front 58

31yr old woman presents with progressive "chest fluttering" for many yrs. Now has signs of R heart failure. Echocardiogram shows fatty replacement of RV myocardium

Back 58

-Arrhythmogenic RV cardiomopathy- fat tissue in RV

Front 59

25yr old woman develops congestive heart failure 3 months after delivering her first child. She has no other pre-disposing conditions or illnesses

Back 59

-cardiomyopathy of pregnancy- can occur up to 6mo after delivery

Front 60

30yr old with Von Hippel Lindau dz has a large benign tumor of the liver?

Back 60

Cavernous hemangiona; occurs in organs

Front 61

27yr old woman has a red nodule on her lip where she has repeatedly bitten it accidentally. It has bled easily and has been present for months?

Back 61

Pyogenic granuloma- associated with trauma

Front 62

37yr old man has an exquisitely painful purple red nodule beneath the fingernail of his left index finger?

Back 62

glomus tumor- arises from glomus body of digits
(setting of endocarditis with "osler's nodes")

Front 63

28yr old pregnant woman has large dilated blood vessels that appeared on the skin surface of her abdomen?

Back 63

Bacillary angiomatosis- immunocompromised, infection related tumor.
(Bartonella species)

Front 64

45yr old liver transplant patient has developed multiple non-painful red skin lesions (macules) on his lower legs

Back 64

-Kaposi Sarcoma- patches stage, earliest onset

Front 65

78yr old German immigrant man has numerous raised, hemorrhagic focally confluent dark red nodules on the skin of his chest?

Back 65

-Kaposi sarcoma; chronic KS (classic/European), NOT HIV associated

Front 66

38yr old man, intermittent episodes of "heart fluttering" associated with syncope. Ultrasound reveals mass in left atrium of heart?

Back 66

Cardiac myxoma- "MOST common cardiac tumor"
(2nd most common is angiosarcoma)

Front 67

Most common malignant cardiac tumor

Back 67

-Angiosarcoma

Front 68

3mo old normal male child has a "holosystolic murmur" since birth?

Back 68

VSD- treatment depends on size of defect
[Holosystolic murmur heard all throughout systole]

Front 69

56yr old man with "heart defect since birth presents with new onset pulmonary HTN

Back 69

Eisenmenger syndrome- untreated ASD or VSD
L > R shunt that became R > L shunt

Front 70

6mo old with aortic atresia has a PDA. What physical sign do you expect to see?

Back 70

-Continuous machinery like murmur- blood continuously flowing through PDA

Front 71

21mo old child with a non-specific "heart murmur" since birth has been squatting on the floor since being able to walk

Back 71

-Tetralogy of Fallot- "pink tetralogy"

Front 72

21yr old man with complaints of lower extremity numbness. Exam shows weak lower extremity pulses and "rib notching" on chest X-ray

Back 72

-Coarctation of aorta- adult variant

Front 73

48yr old obese woman with chronic deep vein thrombosis now presents with symptoms of cerebral infarction

Back 73

-patent foramen ovale- valve like flap over foramen ovale can lead to Paradoxical embolus (or a VSD in which both can cause stroke)