KROK 2

Cardio vascular

 Congenital Cyanotic HD:

 Septal defect- Defect of interventricular septum:

1. Case1:
i. History: Bronchitis and pneumonia (Childhood Murmur)
ii. Findings:
a) splitting of the II heart sound over pulmonary arteria,
systolic murmur (split S1, and fixed splitting of S2. There is a
grade 3/6 midsystolic pulmonic murmur and a 1/6 middiastolic
tricuspid murmur at the lower left sternal border)
b) right bundle-branch block – Atrial Fibrillation
2. Case2:
i. History: physical development is compliant with age
ii. Findings:
a) systolo-diastolic murmur and diastolic shock above
the pulmonary artery, overload of the left heart.
b) Roentgenoscopy shows coarsening of the lung
3. Treatment:
i. Operative Therapy
ii. Cardiac Glucoside

 Patent Ductus Arteriosus: (open Arterial duct)

1. Age: A prematurely born girl is now 8 months old – 29 yo female had
heart murmur when she was a child
2. Symptoms: dyspnea, tachycardia, hepatosplenomegaly, physical
developmental lag, limb cyanosis.
3. Findings: parasternalcardiac hump, auscultation revealed systole-
diastolic murmur in the II intercostal space on the left. BP is 90/0
mm Hg + amplification of the SII above pulmonary artery

 Tetrad of Fallot:
 1. Complains: dyspnea that abates in the sitting position, occasional
loss of consciousness and seizures, delayed physical development,
cyanosis, drumstick fingers
2. Findings: 1. aortic dextra-position, 2. ventricular septal defect,
3.pulmonary artery stenosis, 4. right ventricular hypertrophy

 Aorta coarctation:
1. Complains: headache, nasal haemorrhages,
2. Findings: muscles of shoulder girdle are developed, lower
extremities are hypotrophied. Pulsation on the pedal and femoral
arteries is sharply dampened
3. Treatment: Surgical

 Abdominal Aortic Aneurysm:

1. tumor in the umbilical region and above it; the tumor is 13x8 cm
in size
2. Surgical indications: Any aneurysm greater than 5 cm

 Dissecting aortic aneurysm:

1. Case1:
i. History: Essential Hypertension
ii. Complain: sudden sharp pain in his chest that appeared
when he was lifting a heavy object
iii. Findings: Chest Xray shows a darkening in the upper left
and lower right segments
2. Case2:
i. Complain: dyspnea at rest, marked weakness, and
arrhythmia
ii. Findings: Abdominal aortic pulsation + volumetric formation
in the mesogastrium. Blood pressure is 70/40 mm Hg. There
is no pulsation over the femoral arteries. Oliguria is detected. 
  Heart Failure Cases:

 Heart-Cardiac failure:
1. Complains: dyspnea and edema of shins and feet after physical
exercise, After a long rest or sleep edema diminish
2. Findings: enlarged liver and rasping systolic murmur
3. Puncture: yielded 1000 ml of a liquid with the following properties:
clear, specific gravity - 1,010, protein content - 1%, Rivalta’s test is
negative, erythrocytes - 2-3 in the field of vision

 Diastolic heart failure:

1. History: had hypertrophic cardiomyopathy (Main Cause)
2. Complains: f dyspnea on minimal exertion.
3. Findings: EhoCG reveals asymmetric left ventricular hypertrophy,
signs of pulmonary hypertension, dilatation of the left atrium. EF is
64% (Heart failure with preserved Ef = Diastolic)

 Left Ventricular Failure:

1. History: 15year-long history of essential hypertension and had a
myocardial infarction 2 years ago
2. Symptoms: suddenly developed an asphyxia attack, acrocynosis,
orthopneic,
3. Findings: BP 210/130, dry crackles that become bubbling and non-
resonant

 Hypertensive Crisis complicated by MI :

1. Complain: burning retrosternal pain and asphyxia. She has a 10-
year-long history of essential hypertension
2. Findings:
i. The II heart sound is accentuated over the aorta.
ii. Blood pressure - 210/120 mm Hg
iii. ECG shows elevation of ST segment in the leads I, AVL, and
V5-V6.
 Exertional angina pectoris:
1. Case1: Functional class 3
i. Complain: retrosternal pain that occurs during walks at the
distance of 200 m. (Class 3)
ii. Findings: During cardiopulmonary exercise test at 50 W
there is a depression of S-T segment by 3 mm below the
isoline in V3-V4
2. Case2:
i. Compalin: bursting sensation behind his sternum that
develops during fast walking and physical exertion
ii. Findings: The pain lasts for approximately 5 minutes and
passes on its own in a resting state

 Myocardial Infarction:

 Arrythmias cases:

 Paroxysmal Atrial Tachycadia:

Presentation:
i. sharp acceleration of the heart rate - 240/min., P wave overlaps
with T wave and deforms it, moderate lengthening of PQ interval,
QRS complex is without changes
ii. ECG taken during an attack shows ectopic P waves, QRS wave is
not deformed. At the end of an attack a compensatory pause is
observed

 Paroxysmal Ventricular Tachycardia:

Presentation:  extended QRS complex (0.13 seconds) with heart rate of
160/min., discordant shift of ST segment and T wave, dissociation of atrial
and ventricular rhythm
 Atrial Fibrillation:
History: rheumatism and mitral valve disease with non-disturbed blood
circulation
Presentattion: ECG registers small unevenly-sized waves in place of P-
waves, R-R intervals are of unequal length (Irregular)

 Complete AV-Block:
Presentation: ECG shows P waves disconnected from QRS complexes,
dissociation and diderent rhythm of atria and ventricles is
accompanied by varying location of P wave in relation to QRST complex

 Pacemaker implantation: Complete Av-Block

1. Case1:
i. History: The patient’s father had a history of cardiac
arrhythmias
ii. ECG: heart rate – 215/min, widening and deformation of QRS
complex accompanied by atrioventricular dissociation;
positive P wave. Some time later heart rate reduced down to
45/min, there was a complete dissociation of P wave and
QRST complex
2. Case2:
i. History: 1 year ago had a Q wave myocardial infarction of the
posterior wall of the left ventricle (AV Node Supply)
Findings: For the last 2 weeks he has been suffering from daily attacks of
atrial fibrillation and bradycardia episodes, accompanied by bouts of
vertigo

 Heart Infections Cases: Endo-Myo-

 Non-Rheumatic Myocarditis:
1.  History: after recovery from URTI. He complains of
suffocation
 2. Findings: I heart sound is weakened, short systolyc murmur
in the 4th intercostal area near the left edge of the breastbone
3. Drug: Obsidan

 Acute myocarditis:
1. History: acute respiratory disease a month ago - ill with influenza
2. Complain: shooting heart pain
3. Findings: heart boarders +1,5 cm left side, sounds are muffled, soft
systolic murmur at apex and Botkin’s area; sporadic extrasystoles.
Liver isn’t palpated + ESR 21

 Infectious-allergic myocarditis:
1. History: 2 weeks ago after a respiratory infection - had a flu
2. Complain: dull heart pain for the last 10 days
3. Findings: the heart borders are extended+ Heart sounds are
weak and have triple rhythm + ECG : complete left bundle branch
4. block + ESR 25

 Infective Endrocarditis:
1. History: Drug addicted
2. Complains: cough with bloody expectorations, dyspnea, persistent
fever, and leg edemas. JVD
3. Findings: coarse pansystolic murmur detected above the base of
the xiphoid process

 Obliterating Endarteritis:

1. History: Smoking + Alcohol

2. Complains:  inability to walk more that 100 meters. When he
sleeps, his leg usually hangs down.
 3. Findings: No pulse can be detected on the pedal arteries, while
pulsation of the femoral arteries is retained

 Acute pericarditis:
1. History:

 Exudative Pericarditis:
1. History:

 Constrictive Pericarditis:
1. History:
2.

 Rheumatism cases:

 Juvenile rheumatic arthritis:

1. History: complain : for the last 3 months he presents fusiform

swelling of fingers, ankle joints and knee joint, pain in the upper part
of the sternum and cervical part of the spinal column
2. Symptom: Elevation of body temperature 40

 Acute rheumatic fever:

1. History:
i. was ill with angina 2 weeks ago
ii. had tonsillitis 3 weeks ago
 2. Complain: joint pain and stiffness
3. Findings:
i. enlargement of cardiac dullness by 2 cm, tachycardia,
weakness of the 1st sound, gallop rhythm, weak systolic
murmur near apex.
ii. ESR is 38 mm/h. CRP 2+. AntistreptolysinO titers are 400
4. Question: Where is the left relative heart border located?
Answer: 1 cm left from the left medioclavicular line
5. Drug Prevention: Bicillinum-5
6. Secondary prophylaxis: Year-round bicillin prophylaxis till the age
of 25

 Rheumatic pancarditis:
1. Histoy: acute tonsillitis 2 weeks ago
2. Findings:
i. pericardium friction sound.
ii. ECG: the descent of QRS voltage, the inversion T.
iii. The liver is enlarged by 3 cm. ESR – 4 mm/h, ASL – 0 – 1260,
C-reactive protein +++

 Question: has rheumatism. Over the last 2 years he has had 3 rheumatic
attacks. What course of rheumatism does the patient have?

Answer: Prolonged

 Cardiomyopathies cases:

 Hypertrophic :
1. Case1: ECG showed hypertrophy of the left ventricle, signs of
repolarization disturbance in the I, V5 and V6 leads. Echocardiogram
revealed that interventricular septum was 2 cm
 2. Case2: The patient’s brother died suddenly at the age of 30 (Sudden
death mainly due to Hypertrophy)
3. Medication: Beta Blocker

 Dilated Cardiomyopathy:
1.

 Ventricular Hypertophy:
1. Case1:
i. History:  17-year-long history of chronic obstructive
bronchitis
ii. Complain: dyspnea with difficult inspiration, heaviness in
his right subcostal region, and edema of feet and shins
iii. Findings: rough respiration and dry crackles over the lungs
and an accentuated split-second heart sound in the second
ntercostals region.

 Cardiac Temponade:
1. History case: after receiving a penetrating wound
2. Complain: acrocyanosis, swollen cervical veins, enlarged liver,
ascites. Cardiac borders are dilated
3. Findings: X-ray picture of chest shows enlarged heart shadow
in form of a trapezium.

 Valvular Diseases:

 Aortic stenosis: “Systolic Murmur”

1. Case1:
i. Complain: The liver extends 5 cm from under the edge of
costal arch, shin edemas are present
 ii. Findings: There are crackles in the lower lungs + systolic
thrill in the II ntercostals space on the right , coarse
systolic murmur conducted to the vessels of neck. BP- 130/90
mm Hg
2. Case2:
i. History: with stigmas of dysembryogenesis
ii. Findings: ECG results: hypertrophy of the right ventricle +
systolic murmur in the second ntercostals to the right of the
sternum

 Aortal insufficiency:
heart failure has diastolic pressure of 0 mm Hg

 Mitral Stenosis: “Diastolic Murmur”

1. History: rheumatic patient
2. Findings:
i. accentuated S1 at apex, there is diastolic murmur with
presystolic intensification, opening snap, S2 accent at
pulmonary artery + Border Displacement
ii. the sound of opening mitral valve can be auscultated at
the cardiac apex, dilated pulmonary root
iii. Echocardiocopy revealed abnormal pattern of the mitral
valve motion

 Shock-Syncope-collapse
Cardiogenic shock

 Collapse:
1. Case1: fainted during a meeting. The day before she complained
of a headache + heart rate is 51/min.; BP is 90/50 mm Hg
2. Case2: rapidly changing her position from horizontal to vertical
suddenly paled, fell down + blood pressure is 50/25 mm Hg

 Syncope:
 1. Case1: emotionally labile girl developed severe weakness, dizziness,
blackout, nausea and loss of consciousness without convulsions
2. Case2: During the ultrasound study of carotid and vertebral arteries a 74-
year-old patient developed a condition manifested by dizziness, weakness,
nausea, transient loss of consciousness
3. Case3: During an outdoors school event in hot weather, a 10-year-old girl
lost her consciousness.

 Management:

 Pericardio:
 Polytrauma +  Echocardiogram shows free liquid in the pericardial cavity,
in the amount of up to 100 ml
 X-ray shows trapezoidal cardiac silhouette and signs of pulmonary
congestion

 Beta-Blockers:
 All Cases of Hypertrophy

 Amiodarone:
 Anti Arrythmic drug
 Cases of Extrasystole

 Digoxin:

 Atropine
 III degree atrioventricular heart block
 Oral Anticoagulants:
 Secondery Prevention for Atrial fibrillation from ischemic
Stroke by embolism

 Echocardiograpgy:
 Confirmative diagnosis for systolic murmur at the cardiac
apex, accent of the II heart sound over the pulmonary artery,
tachycardia