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37 Cards in this Set
- Front
- Back
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A 6-month old baby has occasional stridor, and episodes of respiratory distress with "crowing" respiration during which he assumes a hyper-extended position. The family has also noted mild difficulty in swallowing.
What is this? |
Combination of pressure on the esophagus and pressure on the trachea identifies a VASCULAR RING |
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A 6-month old baby has occasional stridor, and episodes of respiratory distress with "crowing" respiration during which he assumes a hyper-extended position. The family has also noted mild difficulty in swallowing.
How should this patient be managed? |
- Barium swallow will show a typical extrinsic compression from the abnormal vessel - Bronchoscopy confirms the segmental tracheal compression and rules out diffuse tracheomalacia - Surgical repair is done by dividing the smaller of the double aortic arches |
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A patient who has a prosthetic aortic and mitral valves needs extensive dental work.
How should this patient be managed? |
- Antibiotic prophylaxis is needed to protect those valves from bacterial contamination - This is to prevent subacute bacterial endocarditis |
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During a school physical exam, a 12-year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognizes that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited.
What is this? |
Atrial Septal Defect |
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During a school physical exam, a 12-year old girl is found to have a heart murmur. She is referred for further evaluation. An alert cardiology fellow recognizes that she indeed has a pulmonary flow systolic murmur, but he also notices that she has a fixed split second heart sound. A history of frequent colds and upper respiratory infections is elicited.
How should this patient be managed? |
- Echocardiography to establish diagnosis - Closure of defect by open surgery or cardiac cath |
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A 3-month old boy is hospitalized for "failure to thrive." He has a loud, pansystolic heart murmur best heard at the left sternal border. CXR shows increased pulmonary vascular markings.
What is this? |
Ventricular Septal Defect |
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A 3-month old boy is hospitalized for "failure to thrive." He has a loud, pansystolic heart murmur best heard at the left sternal border. CXR shows increased pulmonary vascular markings.
How should this patient be managed? |
Echocardiography and surgical correction |
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Because of a heart murmur, an otherwise asymptomatic 3-month old baby is diagnosed with a small, restrictive ventricular septal defect located low in the muscular septum.
How should this patient be managed? |
This particular variant has a good chance to close spontaneously within the first 2-3 years of life |
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A 3-day old premature baby has trouble feeding and pulmonary congestion. Physical exam shows bounding peripheral pulses and a continuous, machinery-like murmur. Shortly thereafter the baby goes into overt heart failure.
What is this? |
Patent ductus arteriosus |
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A 3-day old premature baby has trouble feeding and pulmonary congestion. Physical exam shows bounding peripheral pulses and a continuous, machinery-like murmur. Shortly thereafter the baby goes into overt heart failure.
How should this patient be managed? |
- Echocardiography and surgical closure - In premature infants, surgery is usually reserved for patients who did not close their ductus with indomethacin, but with overt heart failure there is no time to wait - In full-term infants, closure can be achieved with intraluminal coils or surgery |
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A premature baby has mild pulmonary congestion, signs of increased pulmonary blood flow on x-ray, a wide pulse pressure, and a precordial machinery-like murmur. She is not in congestive heart failure.
What is this? |
Patent ductus arteriosus |
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A premature baby has mild pulmonary congestion, signs of increased pulmonary blood flow on x-ray, a wide pulse pressure, and a precordial machinery-like murmur. She is not in congestive heart failure.
How should this patient be managed? |
There is no urgency, given that she is premature, she is a clear candidate for medical treatment with indomethacin; if it fails to close then you can use surgery |
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A 6-year old boy is brought to the US by his new adoptive parents from an orphanage in Eastern Europe. The boy is small for his age and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with squatting. He has a systolic ejection murmur in the left third intercostal space. CXR shows a small heart and diminished pulmonary vascular markings. ECG shows right ventricular hypertrophy.
What is this? |
Tetralogy of Fallot - Cyanotic kids could have any of the five conditions that begin with the letter "T" (tetralogy, transposition of great vessels, truncus arteriosus, total anomalous pulmonary venous connection, or tricuspid atresia) - If the baby went home after birth, and later was found to be cyanotic, bet on tetralogy - If the baby was blue from the moment of birth, bet on transposition |
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A 6-year old boy is brought to the US by his new adoptive parents from an orphanage in Eastern Europe. The boy is small for his age and has a bluish hue in the lips and tips of his fingers. He has clubbing and spells of cyanosis relieved with squatting. He has a systolic ejection murmur in the left third intercostal space. CXR shows a small heart and diminished pulmonary vascular markings. ECG shows right ventricular hypertrophy.
How should this patient be managed? |
- Start with echo to diagnose - Intricate details of surgical correction are not necessary |
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A 72-year old man has a history of angina and exertional syncopal episodes. He has a harsh mid-systolic heart murmur heard best at the right second intercostal space and along the left sternal border.
What is this? |
Aortic stenosis |
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A 72-year old man has a history of angina and exertional syncopal episodes. He has a harsh mid-systolic heart murmur heard best at the right second intercostal space and along the left sternal border.
How should this patient be managed? |
- Diagnose with echo - Surgical valvular replacement is indicated if the gradient is >50 mmHg or at the first indication of CHF, angina, or syncope |
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A 72-year old man has been known for years to have a wide pulse pressure and a blowing, high-pitched, diastolic heart murmur best heard at the right second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation.
What is this? |
Chronic aortic insufficiency |
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A 72-year old man has been known for years to have a wide pulse pressure and a blowing, high-pitched, diastolic heart murmur best heard at the right second intercostal space and along the left lower sternal border with the patient in full expiration. He has had periodic echocardiograms, and in the most recent one there is evidence of beginning left ventricular dilatation.
How should this patient be managed? |
Aortic Valve Replacement |
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A 26-year old drug-addicted man develops CHF over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical exam done a few weeks ago, when he had attempted to enroll in a detox program, was completely normal.
What is this? |
Acute aortic insufficiency caused by endocarditis |
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A 26-year old drug-addicted man develops CHF over a short period of a few days. He has a loud, diastolic murmur at the right, second intercostal space. A physical exam done a few weeks ago, when he had attempted to enroll in a detox program, was completely normal.
How should this patient be managed? |
Emergency valve replacement, and antibiotics for a long time |
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A 35-year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. She has had these progressive symptoms for 5 years. She looks thin and cachectic and has atrial fibrillation and a low-pitched, rumbling diastolic apical heart murmur. At age 15 she had rheumatic fever.
What is this? |
Mitral Stenosis |
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A 35-year old lady has dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, cough, and hemoptysis. She has had these progressive symptoms for 5 years. She looks thin and cachectic and has atrial fibrillation and a low-pitched, rumbling diastolic apical heart murmur. At age 15 she had rheumatic fever.
How should this patient be managed? |
- Start with echo - Eventually, surgical mitral valve repair (mitral commisurotomy), or balloon valvuloplasty |
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A 55-year old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back.
What is this? |
Mitral regurgitation |
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A 55-year old lady has been known for years to have mitral valve prolapse. She now has developed exertional dyspnea, orthopnea, and atrial fibrillation. She has an apical, high-pitched, holosystolic heart murmur that radiates to the axilla and back.
How should this patient be managed? |
- Start with echo - Eventually surgical repair of the valve (annuloplasty) or possibly valve replacement |
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A 55-year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit over weight, has type 2 diabetes mellitus, and has high cholesterol.
What is this? |
Heart attack waiting to happen! |
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A 55-year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit over weight, has type 2 diabetes mellitus, and has high cholesterol.
How should this patient be managed? |
Cardiac cath to see if he is suitable for coronary revascularization |
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A 55-year old man has progressive, unstable, disabling angina that does not respond to medical management. His father and two older brothers died of heart attacks before the age of 50. The patient stopped smoking 20 years ago, but still has a sedentary life style, is a bit over weight, has type 2 diabetes mellitus, and has high cholesterol. Cardiac cath demonstrates 70% occlusion of three coronary arteries, with good distal vessels. His LVEF is 55%.
How should this patient be managed? |
He is lucky. He has good distal vessels (smokers and diabetics often do not) and enough cardiac function left. He clearly needs coronary bypass, and with triple-vessel disease he is clearly not a good candidate for angioplasty. |
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A post-op patient who underwent open heart surgery is determined to have a cardiac index of 1.7 L/min/m^2, and with a LV end diastolic pressure of 3 mmHg.
How should this patient be managed? |
You should be able to recognize a dangerously low cardiac index, without a high end diastolic pressure = a clear indication for increased fluid intake |
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A 72-kg patient who had triple coronary bypass is determined on the second post-op day to have a cardiac output of 2.3 L/min. His pulmonary wedge pressure is 27 mmHg.
What is happening? |
Cardiac output is low, but in this case, the ventricle is failing |
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On a routine pre-employment physical exam, a CXR is done on a 45-year old chronic smoker. A "coin lesion" is found in the upper lobe of the right lung.
What is this? |
Concerning for lung cancer |
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On a routine pre-employment physical exam, a CXR is done on a 45-year old chronic smoker. A "coin lesion" is found in the upper lobe of the right lung.
How should this patient be managed? |
- Find an older CXR if one is available (from one or more years ago) - Workup for cancer of lung is expensive and invasive; on the other hand, lung cancer grows and kills in a predictable way, over a matter of several months - If an older x-ray has the same unchanged lesion, it is not likely cancer - No further work-up is needed now, but the lesion should be followed with periodic x-rays |
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A 65-year old man with a 40 pack year history of smoking gets a CXR because of persistent cough. A peripheral, 2-cm "coin lesion" is found in the right lung. A CXR taken 2 years ago was normal.
What is this? |
Concerning for lung cancer
Above age 50, "coin lesions" have an 80% chance of being malignant; in this man it is almost certainly lung cancer |
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A 65-year old man with a 40 pack year history of smoking gets a CXR because of persistent cough. A peripheral, 2-cm "coin lesion" is found in the right lung. A CXR taken 2 years ago was normal.
How should this patient be managed? |
- Next step after CXR consists of non-invasive ways to establish the diagnosis and some idea of the extension of the tumor (about 2/3 are already beyond surgical state when first seen) - If other findings do not dictate a different approach, start with SPUTUM CYTOLOGY and CT SCAN (including upper abdomen to detect liver metastasis) - Next step (if needed) would be BIOPSY of the mass, by BRONCHOSCOPY (if central) or PERCUTANEOUS (if peripheral) |
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A 66-year old man with a 40 pack year history of smoking gets a CXR because of persistent cough. A peripheral 2-cm "coin lesion" is found in the right lung. A CXR 2 years ago was normal. CT scan shows no calcifications in the mass, no liver metastases, and no enlarged peribronchial or peritracheal lymph nodes. Sputum cytology, bronchoscopy, and percutaneous needle biopsy have not been diagnostic. The man has good pulmonary function and is otherwise in good health.
How should this patient be managed? |
In dealing with cancer of the lung, there is an interplay of three issues: 1. Establishing diagnosis (requires very invasive steps) 2. Ascertaining whether surgery can be done (ie, will the pt still be functional after some lung tissue is removed) 3. Does surgery have a fair chance to cure him (it will not if tumor is extensive)
This man could stand lung resection (peripheral lesion, good function) and who stands a good chance for cure (no node metastases in CT)
Diagnostic steps should be pushed to the limit, ie, thoracotomy and wedge resection |
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A 72-year old chronic smoker with severe COPD is found to have a central, hilar mass on CXR. Sputum cytology establishes a diagnosis of squamous cell carcinoma of the lung. His forced expiratory volume in 1 second (FEV1) is 1,100 ml, and a ventilation-perfusion scan shows that 60% of pulmonary function comes from affected lung.
How should this patient be managed? |
- H&P suggested that main limiting factor would be pulmonary function, thus that issue was properly evaluated first - It takes an FEV1 of at least 800 ml to survive surgery and not be a pulmonary cripple afterward - If this fellow underwent a pneumonectomy (which is indicated for central tumor), he would be left with FEV1 of 440 ml - He cannot live a quality life with that low of an FEV1 so stop doing tests, he is not a surgical candidate; you can pursue CHEMO and RADIATION |
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A 62-year old chronic smoker has an episode of hemoptysis. CXR shows a central hilar mass. Bronchoscopy and biopsy establish a diagnosis of squamous cell carcinoma of the lung. His FEV1 is 2200 ml and a VQ scan shows that 30% of his pulmonary function comes from the affected lung.
How should this patient be managed? |
- This patient could tolerate a pneumonectomy, but will still have to determine the extent of his disease - CT scan alone may be able to establish that he does not have metastasis - CT plus PET may be required in some cases where the status of the mediastinal nodes is not clear, and if the PET scan cannot provide an answer, an endobronchial U/S to sample nodes would be the next step |
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A 33-year old woman is undergoing a diagnostic workup because she appears to have Cushing syndrome. CXR shows a central 3-cm round mass on the right lung. Bronchoscopy and biopsy confirm a diagnosis of small cell carcinoma of the lung.
How should this patient be managed? |
RADIATION and CHEMOTHERAPY
Small cell lung cancer is not treated with surgery, thus we have no need to determine FEV1 or nodal status |
