Medicine Marrow Pg 291-300 (Cardiology)
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Medicine Marrow Pg 291-300 (Cardiology)

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Questions and Answers

What condition is associated with an incompetent valve leaflet leading to regurgitation?

  • Aortic Stenosis
  • Pulmonary Stenosis
  • Tricuspid Regurgitation
  • Mitral Regurgitation (correct)

    • 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?

    Decreases

    The ______ of isovolumetric contraction indicates the rate of rise of pressure in a closed ventricle.

    <p>dP/dt</p> Signup and view all the answers

    Match the following conditions with their corresponding characteristics:

    <p>Mitral Stenosis = Delayed closure leading to a loud S Aortic Regurgitation = Premature closure leading to a soft S Bradycardia = Soft S due to increased PR interval Tachycardia = Loud S due to decreased PR interval</p> Signup and view all the answers

    Which of the following is NOT associated with S1 in the cardiac cycle?

    <p>Valve closure - S2</p> Signup and view all the answers

    The Hangout Interval refers to the time between crossover pressure and the opening of the aortic and pulmonary valves.

    <p>False</p> Signup and view all the answers

    What mechanical condition is indicated by a T1 before m1 in reverse split?

    <p>Early closure of the mitral valve is indicated by T1 before m1.</p> Signup and view all the answers

    During inspiration, the gap between A2 and P2 can increase to greater than ______ milliseconds.

    <p>50</p> Signup and view all the answers

    Match the following conditions with their descriptions in the context of Reverse Split:

    <p>Right-sided pacing = Electrical condition affecting the heart's rhythm LBBB = Mechanical delay in left ventricular contraction LA myxoma = A tumor in the left atrium causing mechanical obstruction T1 before m1 = Indicates early mechanical closure of the mitral valve</p> Signup and view all the answers

    Which feature distinguishes high frequency heart sounds?

    <p>Soft musical/blowing sound</p> Signup and view all the answers

    Low frequency sounds are better heard with the diaphragm of a stethoscope.

    <p>False</p> Signup and view all the answers

    What is the primary characteristic of ejection systolic murmurs (Esm) in aortic stenosis?

    <p>Harsh murmur</p> Signup and view all the answers

    High frequency sounds are measured in ________.

    <p>hertz</p> Signup and view all the answers

    Match the heart sound types to their characteristics:

    <p>High Frequency = Heard best with diaphragm Low Frequency = Heard best with bell Ejection Systolic Murmur = Harsh murmur, right ICS S3 and S4 = Heard with bell, low pitch</p> Signup and view all the answers

    What indicates a soft S₁ in aortic regurgitation?

    <p>Loss of dp/dt of Isovolumetric contraction</p> Signup and view all the answers

    Loud S₁ is always indicative of severe valvular heart disease.

    <p>False</p> Signup and view all the answers

    What heart condition is associated with a delayed closure leading to loud S₁?

    <p>Mitral Stenosis</p> Signup and view all the answers

    In cases of _________, varying S₁ is observed due to varying cycle lengths.

    <p>atrial fibrillation</p> Signup and view all the answers

    Match the following conditions with their associated S₁ characteristics:

    <p>Aortic Stenosis = Normal S₁ Aortic Regurgitation = Soft S₁ Mitral Stenosis = Loud S₁ Mitral Regurgitation = Soft S₁</p> Signup and view all the answers

    Which of the following conditions can present with a loud heart sound due to calcific immobile leaflet?

    <p>Aortic Stenosis</p> Signup and view all the answers

    Intermittent S₁ can occur in complete heart block with AV dissociation.

    <p>True</p> Signup and view all the answers

    A loud S₁ can often be confused for S₁ due to aortic ejection click caused by a _________.

    <p>bicuspid aortic valve</p> Signup and view all the answers

    During which phase of the cardiac cycle is the heart primarily filling with blood?

    <p>Diastole</p> Signup and view all the answers

    The S1 heart sound corresponds to the closure of the AV valves.

    <p>True</p> Signup and view all the answers

    What percentage of ventricular filling occurs during atrial systole?

    <p>30%</p> Signup and view all the answers

    During rapid filling, the AV valves are ______.

    <p>open</p> Signup and view all the answers

    Match the following phases of the cardiac cycle with their descriptions:

    <p>Systole = Blood is ejected from the heart Diastole = Heart chambers fill with blood Isovolumetric Contraction = Pressure increases without volume change Atrial Systole = Atria contract to complete ventricular filling</p> Signup and view all the answers

    What is the most important risk factor for invasive aspergillosis?

    <p>Neutropenia</p> Signup and view all the answers

    The air crescent sign indicates the presence of an ongoing invasive aspergillosis infection.

    <p>False</p> Signup and view all the answers

    List two classical clinical manifestations of invasive aspergillosis.

    <p>Fever, Hemoptysis</p> Signup and view all the answers

    The __________ is a sign that consists of ground glass opacification surrounded by consolidation, suggesting invasive aspergillosis.

    <p>halo sign</p> Signup and view all the answers

    Match the following signs with their descriptions:

    <p>Halo sign = Consolidation surrounded by ground glass opacification Air crescent sign = Crescent in consolidation indicating recovery Reverse halo sign = Ground glass opacification surrounded by consolidation Monad sign = Air crescent seen around fungal ball in TB</p> Signup and view all the answers

    What is considered the gold standard for diagnosing conditions related to pulmonary issues?

    <p>PCR</p> Signup and view all the answers

    The primary treatment for mild to moderate fungal pneumonia is oral Clindamycin.

    <p>False</p> Signup and view all the answers

    What microscopy method is best for diagnosing the cyst form in pulmonary infections?

    <p>Methenamine silver stain</p> Signup and view all the answers

    In patients with HIV, the most common cause of pleural effusion is ______.

    <p>fungal pneumonia</p> Signup and view all the answers

    Match the following treatments with their corresponding severity of pneumonia:

    <p>Mild to moderate = Oral Cotrimoxazole Severe = IV Cotrimoxazole Fallback option = Clindamycin + Primaquine IV with higher side effects = IV Pentamidine</p> Signup and view all the answers

    Which organism is NOT commonly associated with pneumonia in severely immunocompromised individuals?

    <p>Streptococcus pneumoniae</p> Signup and view all the answers

    Infections due to BK polyoma virus typically occur more than six months post renal transplant.

    <p>False</p> Signup and view all the answers

    Name one drug that can cause drug-induced neutropenia in post-transplant recipients.

    <p>Mycophenolate mofetil</p> Signup and view all the answers

    The primary organisms responsible for pneumonia in immunocompromised patients include _____ Gram-negative bacteria.

    <p>MDR</p> Signup and view all the answers

    Match the following types of transplants with their associated infections:

    <p>Renal Transplant = Nocardia Bone Marrow Transplant = Aspergillus Any transplant = Cytomegalovirus (CMV) Lung Transplant = Pneumocystis jirovecii</p> Signup and view all the answers

    What is the primary mode of transmission for Nocardia asteroides?

    <p>Inhalation and through skin defect</p> Signup and view all the answers

    Nocardia asteroides is a non-acid fast organism.

    <p>False</p> Signup and view all the answers

    What is the drug of choice (DOC) for treating Nocardia asteroides?

    <p>Sulfonamide</p> Signup and view all the answers

    The clinical manifestation of a subacute brain abscess is associated with Nocardia asteroides, specifically in the _______ system.

    <p>CNS</p> Signup and view all the answers

    Match the following characteristics to the correct organism:

    <p>Nocardia asteroides = Acid fast, filamentous fungi Actinomycetes = Non-acid fast, non-aerobic Rhodococci = Acid fast, non-filamentous</p> Signup and view all the answers

    What is the most appropriate first-line treatment for invasive aspergillosis?

    <p>Voriconazole</p> Signup and view all the answers

    The β-D-glucan test is negative for mucor infections.

    <p>True</p> Signup and view all the answers

    What specific findings distinguish mucormycosis from aspergillosis in microscopic examination?

    <p>Aseptate hyphae and right angle branching.</p> Signup and view all the answers

    Pneumocystis jirovecii infections are primarily seen in individuals with a CD4 count below _______ cells per microliter.

    <p>200</p> Signup and view all the answers

    Match the following treatments with the respective fungal infections:

    <p>Voriconazole = Invasive aspergillosis Liposomal amphotericin B = Mucormycosis Fluconazole = Candida infections Posaconazole = Mucormycosis adjunctive therapy</p> Signup and view all the answers

    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
    • 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
    • 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

    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

    Features High Frequency Low Frequency
    Pressure difference between chambers Soft musical/blowing sound Rough rumbling or thud-like
    Area heard Wide Low
    Thrill Wider Localized
    Better heard with Absent Present
    Examples Diaphragm of a stethoscope, most heart sounds in cardiology Bell, 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

    Phase Description
    Systole (0.3 s) 1. Isovolumetric Contraction 2. Rapid ejection 3. Reduced ejection
    Diastole (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
    • 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.

    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
    • Bone Marrow Transplant:
      • 6 months:
        • Drug-induced neutropenia (mycophenolate mofetil, calcineurin inhibitors)
        • Infection by BK polyoma virus
        • Nocardia
        • Aspergillus

    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.

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