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Questions and Answers
What condition is associated with an incompetent valve leaflet leading to regurgitation?
What condition is associated with an incompetent valve leaflet leading to regurgitation?
Normal valve position at the end of diastole is completely open.
Normal valve position at the end of diastole is completely open.
False
What happens to the intensity of auscultatory events when there is obesity or emphysema?
What happens to the intensity of auscultatory events when there is obesity or emphysema?
Decreases
The ______ of isovolumetric contraction indicates the rate of rise of pressure in a closed ventricle.
The ______ of isovolumetric contraction indicates the rate of rise of pressure in a closed ventricle.
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Match the following conditions with their corresponding characteristics:
Match the following conditions with their corresponding characteristics:
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Which of the following is NOT associated with S1 in the cardiac cycle?
Which of the following is NOT associated with S1 in the cardiac cycle?
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The Hangout Interval refers to the time between crossover pressure and the opening of the aortic and pulmonary valves.
The Hangout Interval refers to the time between crossover pressure and the opening of the aortic and pulmonary valves.
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What mechanical condition is indicated by a T1 before m1 in reverse split?
What mechanical condition is indicated by a T1 before m1 in reverse split?
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During inspiration, the gap between A2 and P2 can increase to greater than ______ milliseconds.
During inspiration, the gap between A2 and P2 can increase to greater than ______ milliseconds.
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Match the following conditions with their descriptions in the context of Reverse Split:
Match the following conditions with their descriptions in the context of Reverse Split:
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Which feature distinguishes high frequency heart sounds?
Which feature distinguishes high frequency heart sounds?
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Low frequency sounds are better heard with the diaphragm of a stethoscope.
Low frequency sounds are better heard with the diaphragm of a stethoscope.
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What is the primary characteristic of ejection systolic murmurs (Esm) in aortic stenosis?
What is the primary characteristic of ejection systolic murmurs (Esm) in aortic stenosis?
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High frequency sounds are measured in ________.
High frequency sounds are measured in ________.
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Match the heart sound types to their characteristics:
Match the heart sound types to their characteristics:
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What indicates a soft S₁ in aortic regurgitation?
What indicates a soft S₁ in aortic regurgitation?
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Loud S₁ is always indicative of severe valvular heart disease.
Loud S₁ is always indicative of severe valvular heart disease.
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What heart condition is associated with a delayed closure leading to loud S₁?
What heart condition is associated with a delayed closure leading to loud S₁?
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In cases of _________, varying S₁ is observed due to varying cycle lengths.
In cases of _________, varying S₁ is observed due to varying cycle lengths.
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Match the following conditions with their associated S₁ characteristics:
Match the following conditions with their associated S₁ characteristics:
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Which of the following conditions can present with a loud heart sound due to calcific immobile leaflet?
Which of the following conditions can present with a loud heart sound due to calcific immobile leaflet?
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Intermittent S₁ can occur in complete heart block with AV dissociation.
Intermittent S₁ can occur in complete heart block with AV dissociation.
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A loud S₁ can often be confused for S₁ due to aortic ejection click caused by a _________.
A loud S₁ can often be confused for S₁ due to aortic ejection click caused by a _________.
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During which phase of the cardiac cycle is the heart primarily filling with blood?
During which phase of the cardiac cycle is the heart primarily filling with blood?
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The S1 heart sound corresponds to the closure of the AV valves.
The S1 heart sound corresponds to the closure of the AV valves.
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What percentage of ventricular filling occurs during atrial systole?
What percentage of ventricular filling occurs during atrial systole?
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During rapid filling, the AV valves are ______.
During rapid filling, the AV valves are ______.
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Match the following phases of the cardiac cycle with their descriptions:
Match the following phases of the cardiac cycle with their descriptions:
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What is the most important risk factor for invasive aspergillosis?
What is the most important risk factor for invasive aspergillosis?
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The air crescent sign indicates the presence of an ongoing invasive aspergillosis infection.
The air crescent sign indicates the presence of an ongoing invasive aspergillosis infection.
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List two classical clinical manifestations of invasive aspergillosis.
List two classical clinical manifestations of invasive aspergillosis.
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The __________ is a sign that consists of ground glass opacification surrounded by consolidation, suggesting invasive aspergillosis.
The __________ is a sign that consists of ground glass opacification surrounded by consolidation, suggesting invasive aspergillosis.
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Match the following signs with their descriptions:
Match the following signs with their descriptions:
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What is considered the gold standard for diagnosing conditions related to pulmonary issues?
What is considered the gold standard for diagnosing conditions related to pulmonary issues?
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The primary treatment for mild to moderate fungal pneumonia is oral Clindamycin.
The primary treatment for mild to moderate fungal pneumonia is oral Clindamycin.
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What microscopy method is best for diagnosing the cyst form in pulmonary infections?
What microscopy method is best for diagnosing the cyst form in pulmonary infections?
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In patients with HIV, the most common cause of pleural effusion is ______.
In patients with HIV, the most common cause of pleural effusion is ______.
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Match the following treatments with their corresponding severity of pneumonia:
Match the following treatments with their corresponding severity of pneumonia:
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Which organism is NOT commonly associated with pneumonia in severely immunocompromised individuals?
Which organism is NOT commonly associated with pneumonia in severely immunocompromised individuals?
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Infections due to BK polyoma virus typically occur more than six months post renal transplant.
Infections due to BK polyoma virus typically occur more than six months post renal transplant.
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Name one drug that can cause drug-induced neutropenia in post-transplant recipients.
Name one drug that can cause drug-induced neutropenia in post-transplant recipients.
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The primary organisms responsible for pneumonia in immunocompromised patients include _____ Gram-negative bacteria.
The primary organisms responsible for pneumonia in immunocompromised patients include _____ Gram-negative bacteria.
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Match the following types of transplants with their associated infections:
Match the following types of transplants with their associated infections:
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What is the primary mode of transmission for Nocardia asteroides?
What is the primary mode of transmission for Nocardia asteroides?
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Nocardia asteroides is a non-acid fast organism.
Nocardia asteroides is a non-acid fast organism.
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What is the drug of choice (DOC) for treating Nocardia asteroides?
What is the drug of choice (DOC) for treating Nocardia asteroides?
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The clinical manifestation of a subacute brain abscess is associated with Nocardia asteroides, specifically in the _______ system.
The clinical manifestation of a subacute brain abscess is associated with Nocardia asteroides, specifically in the _______ system.
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Match the following characteristics to the correct organism:
Match the following characteristics to the correct organism:
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What is the most appropriate first-line treatment for invasive aspergillosis?
What is the most appropriate first-line treatment for invasive aspergillosis?
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The β-D-glucan test is negative for mucor infections.
The β-D-glucan test is negative for mucor infections.
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What specific findings distinguish mucormycosis from aspergillosis in microscopic examination?
What specific findings distinguish mucormycosis from aspergillosis in microscopic examination?
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Pneumocystis jirovecii infections are primarily seen in individuals with a CD4 count below _______ cells per microliter.
Pneumocystis jirovecii infections are primarily seen in individuals with a CD4 count below _______ cells per microliter.
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Match the following treatments with the respective fungal infections:
Match the following treatments with the respective fungal infections:
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Study Notes
S1 in Valvular Heart Disease
- Aortic Stenosis (AS): Normal S1
- Aortic Regurgitation (AR): Soft S1 due to premature valve closure
- Mitral Stenosis (MS): Loud S1 due to delayed valve closure, increased velocity, and wide apart valve position
- Mitral Regurgitation (MR): Soft S1 due to loss of integrity and loss of dP/dt of isovolumetric contraction
- Loud S1:
- Can be heard in conditions other than valvular heart disease, including:
- Tricuspid Stenosis (TS)
- Atrial Septal Defect (ASD)
- Total Anomalous Pulmonary Venous Connection
- Can be heard in conditions other than valvular heart disease, including:
- Bicuspid Aortic Valve:
- Presents with loud S1
- Aortic ejection click can be mistaken for S1
- Rheumatic fever-induced MR with preserved leaflet:
- Soft S1 due to associated myocarditis
- MS + MR:
- Severity of the sound depends on what condition dominates
- TR in MS:
- Moderate MS can lead to pulmonary hypertension, RV hypertrophy, and TR, resulting in a soft S1.
- Mild Secondary MR:
- Often presents with a soft S1 due to papillary and LV dysfunction
- Variable S1:
- Can be impacted by several factors:
- Atrial fibrillation: S1 varies due to fluctuating cycle lengths
- Varying force of ventricular contraction
- Atrial flutter
- Can be impacted by several factors:
- Intermittent S1:
- Complete heart block with AV dissociation: Cannon S1
- Ventricular tachycardia with AV dissociation: Cannon S1
Wide Split S1
- Early m1:
- Ectopic origin from LV
- LV pacing
- Mechanical:
- Ebstein anomaly:
- Sail sound due to loud T1
- Ebstein anomaly:
Delay between m1 and T1:
- Late T1:
- RBBB
- TS
- RA Myxoma
Reverse Split
- Electrical:
- Early T1
- Right-sided pacing
- Right-sided ectopic
- Mechanical:
- T1 before m1
- Delayed m1:
- LBBB
- MS
- LA myxoma
Factors Affecting Intensity of S1
- Integrity of Valve Leaflet:
- Incompetent valve leaflet (leaky) -> Regurgitation (MR)
- Perforation of leaflet (Infective endocarditis)
- Calcific for immobile leaflet (Calcific MS)
- Position of Leaflet at End of Diastole:
- Normal: Semiclosed position floating in the filled LV
- Valve stenosis -> Reduced LV filling -> Valve wide apart at the base in the open position
- Loud S1 due to valves closing from a greater distance
- Velocity of Contraction:
- Valves closing from distance -> ↑ velocity -> loud S1
- Bradycardia: Soft S1 -> ↑ PR interval (diastole) -> ↑ filling -> valve are closer -> ↓ velocity
- Tachycardia: Loud S1 -> ↓ PR interval -> ↓ filling -> valve close from distance -> ↑ velocity
- Timing of Closure:
- Delayed closure: Loud S1 -> eg. MS (↑ LAP) -> More time for LVP > LAP -> Delayed closure
- Premature closure: Soft S1 -> eg. AR (LVP ↑ rapidly) -> Quick LVP > LAP -> Premature closure
- dP/dt of Isovolumetric Contraction:
- Rate of rise of pressure in the closed ventricle
- Leaky valve -> Ineffective IVC -> loss of dP/dt-> ↓ velocity -> soft S1
- (MR, myocarditis)
- Exercise, high output state -> ↑ myocardial contractility -> ↑ dP/dt -> loud S1
- Transmission Characteristics of the Thoracic Cavity & Chest Wall:
- Obesity, emphysema, pericardial effusion -> ↓ intensity of all auscultatory events
- Thin chest wall -> ↑ intensity -> loud S1
Cardiac Cycle with Heart Sounds
- Brief, discrete auditory vibrations
Identifying Features
- Intensity (Loudness): Measured in decibels (dB)
- Frequency (Pitch): Measured in Hertz (Hz)
- Frequency ∝\propto∝ Amplitude/intensity
Types of Heart Sounds
FeaturesHigh FrequencyLow FrequencyPressure difference between chambersSoft musical/blowing soundRough rumbling or thud-likeArea heardWideLowThrillWiderLocalizedBetter heard withAbsentPresentExamplesDiaphragm of a stethoscope, most heart sounds in cardiologyBell, Exceptions: Sounds S3, S4, tumor plop. Murmur: MS, TS, Austin Flint
- Mixed Frequency Sound:
- Ejection Systolic Murmur (Esm) in AS - Harsh murmur and right ICS
- 2 components:
- Low pitch radiates to carotid
- High pitch radiates to apex (Gallavardin phenomenon)
- Cardiac cycle: 0.8 seconds (Atria: 0.1 s systole, 0.7 s diastole)
Cardiac Cycle Phases
PhaseDescriptionSystole (0.3 s)1. Isovolumetric Contraction 2. Rapid ejection 3. Reduced ejectionDiastole (0.5 s)1. Protodiastole 2. Isovolumetric Relaxation (IVR) 3. Rapid filling 4. Reduced filling 5. Atrial systole
- Reduced filling:
- AV valves are open
- 70% of ventricles filled
- Passive filling
- Atrial systole: (30%) ventricular filling (Active)
- Ventricular pressure > atrial
- AV valves close (S1)
S1 Heart Sound
- Introduction:
- Valve apparatus:
- Leaflet (cusp)
- Fibrous annulus
- Commissures
- Valve apparatus:
- Components:
- mI: Closure of mV
- TI: Closure of TV
- Factors affecting the intensity of S1:
- Valve leaflet integrity
- Position of leaflet at end of diastole
- Velocity of contraction
- Timing of closure
- dP/dt of isovolumetric contraction
- Transmission characteristics of the thoracic cavity and chest wall
- Cardiac cycle phases:
- Systole: Isovolumetric contraction, rapid ejection, reduced ejection
- Diastole: Protodiastole, isovolumetric relaxation, rapid filling, reduced filling, atrial systole
Invasive Aspergillosis
- Etiopathogenesis: Conidia/conidiospores (aerosolized from the mold form) reach tissues and form invasive filaments (hyphae)
- Risk factors: Neutropenia (most important)
- CT Signs:
- Halo Sign: Consolidation surrounded by GGO, Suggestive of invasive aspergillosis
- Air Crest Sign: Indicates recovery, Crescent in consolidation
- Note:
- Reverse halo sign: GGO surrounded by Consolidation. Seen in cryptogenic organizing pneumonia
- Monad sign in X-ray: Air crescent seen around fungal ball. Moves with change in position. Seen in aspergilloma in old case of TB.
- Clinical Manifestations:
- Classical presentation:
- Fever
- Hemoptysis
- Pleuritic pain
- Complications:
- Sinus infection (100% mortality)
- CNS infection (100% mortality)
- Angioinvasion → Hemorrhagic infarction.
- Classical presentation:
Pneumonia in Immunocompromised Patients
- Severely immunocompromised:
- Neutropenia (any cause)
- Post-transplant recipients
- High-dose steroid use (>30 mg for 3-4 weeks)
- Organisms:
- MDR Gram-negative bacteria
- Aspergillus
- Nocardia
- Pneumocystis jirovecii
- Toxoplasma
- Cytomegalovirus (CMV)
- Candida
Post Transplant Infections
- Renal transplant:
- 6 months:
- Drug-induced neutropenia (mycophenolate mofetil, calcineurin inhibitors)
- Infection by BK polyoma virus
- Nocardia
- Aspergillus
- 6 months:
- Bone Marrow Transplant:
- 6 months:
- Drug-induced neutropenia (mycophenolate mofetil, calcineurin inhibitors)
- Infection by BK polyoma virus
- Nocardia
- Aspergillus
- 6 months:
Nocardia asteroides
- Microbiological Features:
- Gram-positive filamentous fungi
- Aerobic
- Acid fast
- Filamented mycelia
- Presentation:
- Transmission: Host defense defect is mandatory and transmission occurs via inhalation or through a skin defect.
- Clinical Manifestations:
- CNS: Subacute brain abscess
- Lung:
- Cavitating nodules
- Nocardial mycetoma
- Diagnosis:
- Sputum/pus:
- Crooked branching beaded filaments
- Acid fast
- Culture not done d/t slow growth
- Treatment:
- Sulfonamide (DOC), minocycline
- Amikacin (Parenteral)
- Note:
- Actinomycetes: Non-acid fast, non-aerobic
- Rhodococci: Acid fast, non-filamentous
Diagnosis of Invasive Aspergillosis
- 1,3 β-D-glucan test positive (Non specific)
- ↑ LDH
- BAL: microscopy
- Best mode of diagnosis
- Methenamine silver stain (GMS): Cyst form
- Fluorescein conjugated monoclonal antibody
- PCR: Gold standard
- Chest X-ray (Image Included):
- Diffuse infiltrates at perihilar region
- Cavity, pneumothorax
- Pneumatocele
Management of Atypical Pneumonia & Pneumonia in Immunocompromised Patients
- Diagnosis:
- BAL: Dichotomous branching septate hyphae
- VATS (Video-assisted thoracoscopic surgery): Biopsy from nodule
- Galactomannan test: Specific for invasive aspergillosis
- β-D-glucan test: Positive for mucor, cryptococcus, candida, aspergillosis, pneumocystis
- Treatment:
- Voriconazole (DOC)
- Liposomal amphotericin B
- Note (Findings of Mucormysosis):
- Aseptate hyphae
- Right angle branching
- Negative galactomannan test
- No response to voriconazole
- Rx: Liposomal amphotericin B with posaconazole + surgical debridement of infected tissue
Pneumocystis jirovecii Infections
- Fungal Infection:
- Seen in HIV (CD4 count < 200/µL), immunocompromised individuals
- Clinical Features:
- Dyspnea
- Hypoxemia
- Fever, cough (2-3 days)
- Images:
- CT scan of the lungs
- CXR (Chest X-ray)
- Microscopic view
- Additional Notes:
- Pneumocystis jirovecii infections can manifest with findings of non-specific aspergillosis on CT scans and chest x-rays.
- Microscopic examination of these fungal elements is a common confirmatory method.
- Patients with HIV and a CD4 count below 200 cells/µL are at a high risk of P. jirovecii pneumonia.
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Description
This quiz focuses on the assessment of S1 heart sounds in various valvular heart diseases, including aortic stenosis, aortic regurgitation, mitral stenosis, and mitral regurgitation. Explore how different conditions influence the intensity and quality of the S1 heart sound, and learn to differentiate between normal and abnormal findings.
