Cardio Path Q

[MudPhud20XX]

A 62-year-old man has had episodes of chest pain during the past 5 years, with a myocardial infarction documented 2 years ago. He has had episodes of abdominal pain over the past month. On physical examination, bowel sounds are present. On palpation of the abdomen there is a midline pulsatile mass. Dorsalis pedis and posterior tibial pulses are barely palpable. An abdominal CT scan reveals the lesion shown in the image. Which following laboratory test finding is he most likely to have?

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[MudPhud20XX]

A 33-year-old man is able to run marathon races with a respectable time for his age group. On physical examination his vital signs include heart rate of 70 bpm and blood pressure 120/75 mmHg. There are no remarkable findings. Which congenital heart diseases is he most likely to have?

 

[lunalight]

A 62-year-old man has had episodes of chest pain during the past 5 years, with a myocardial infarction documented 2 years ago. He has had episodes of abdominal pain over the past month. On physical examination, bowel sounds are present. On palpation of the abdomen there is a midline pulsatile mass. Dorsalis pedis and posterior tibial pulses are barely palpable. An abdominal CT scan reveals the lesion shown in the image. Which following laboratory test finding is he most likely to have?

High CRP
Elevated sed rate
High LDL/low HDL?
Possibly elevated blood glucose

A 33-year-old man is able to run marathon races with a respectable time for his age group. On physical examination his vital signs include heart rate of 70 bpm and blood pressure 120/75 mmHg. There are no remarkable findings. Which congenital heart diseases is he most likely to have?

Bicuspid aortic valve

 

[pathologyDO]

A 62-year-old man has had episodes of chest pain during the past 5 years, with a myocardial infarction documented 2 years ago. He has had episodes of abdominal pain over the past month. On physical examination, bowel sounds are present. On palpation of the abdomen there is a midline pulsatile mass. Dorsalis pedis and posterior tibial pulses are barely palpable. An abdominal CT scan reveals the lesion shown in the image. Which following laboratory test finding is he most likely to have?

Lab tests? Looks like he probably has an AAA but can't really think of what lab values which might be important.

 

[Gdl88]

A 62-year-old man has had episodes of chest pain during the past 5 years, with a myocardial infarction documented 2 years ago. He has had episodes of abdominal pain over the past month. On physical examination, bowel sounds are present. On palpation of the abdomen there is a midline pulsatile mass. Dorsalis pedis and posterior tibial pulses are barely palpable. An abdominal CT scan reveals the lesion shown in the image. Which following laboratory test finding is he most likely to have?

Eleveted d dimer? The wall seems thicker.

What is the "black spot" inside the left kidney?

 

[lunalight]

Lab tests? Looks like he probably has an AAA but can't really think of what lab values which might be important.

I was wondering that too. Curious to find out what the answer is.

 

[MudPhud20XX]

I was wondering that too. Curious to find out what the answer is.

He has an abdominal atherosclerotic aneurysm at risk for rupture because of the size. There is a 6-cm-diameter enlargement of the abdominal aorta below the renal arteries that is partially filled with thrombus. Bright areas representing calcifications are seen in the aortic wall. Complications of atherosclerosis are more likely in persons with risk factors such as low HDL cholesterol and high homocysteine.

 

[MudPhud20XX]

High CRP
Elevated sed rate
High LDL/low HDL?
Possibly elevated blood glucose



Bicuspid aortic valve

correct!, how did you know that this was bicuspid aortic valve?

 

[MudPhud20XX]

A 47-year-old woman is brought to the emergency room unconscious. On physical examination her heart sounds are faint. Her blood pressure is 80/50 mmHg, and a paradoxical pulse with a greater than 10 mmHg inspiratory decrease in systolic arterial pressure is noted. There is an area of red discoloration and swelling beneath the skin of her anterior chest. The representative gross appearance of the abnormality is shown in the image. Which condition is most likely produced these findings?

 

[Transposony]

A 47-year-old woman is brought to the emergency room unconscious. On physical examination her heart sounds are faint. Her blood pressure is 80/50 mmHg, and a paradoxical pulse with a greater than 10 mmHg inspiratory decrease in systolic arterial pressure is noted. There is an area of red discoloration and swelling beneath the skin of her anterior chest. The representative gross appearance of the abnormality is shown in the image. Which condition is most likely produced these findings?

Cardiac tamponade due to Hemopericardium.

 

[MudPhud20XX]

good job.. you are right... how did you know? What was the clue from the question stem?

 

[MudPhud20XX]

A 27-year-old man with a history of injection drug use develops a high fever. On physical examination, his temperature is 39.3° C (102.7° F). He has a loud heart murmur. An echocardiogram reveals 1- to 2-cm vegetations on two cusps of his aortic valve. A chest radiograph demonstrates bilateral pulmonary edema. What complication of his disease is he most likely to develop?

 

[Instatewaiter]

good job.. you are right... how did you know? What was the clue from the question stem?

Might have been the pulus paradoxus.

 

[Instatewaiter]

A 62-year-old man has had episodes of chest pain during the past 5 years, with a myocardial infarction documented 2 years ago. He has had episodes of abdominal pain over the past month. On physical examination, bowel sounds are present. On palpation of the abdomen there is a midline pulsatile mass. Dorsalis pedis and posterior tibial pulses are barely palpable. An abdominal CT scan reveals the lesion shown in the image. Which following laboratory test finding is he most likely to have?

So this looks like a AAA but given the diinished dorsalis pedis pulse and posterior tibial puse you worry about intramural hematoma (ie a dissection equvalent). It is rare for a AAA to cause abdominal pain unless it is compression another structure or it has ruptured/dissected. The image shows a ver large AAA which based on the image looks like it is larger than 6cm. Given the image, it is less likely to be an intramural hematoma (and more likley an intraluminal thrombsu) because there are calcifications inside the thrombus.

The answer could be one of a hundred things- High LDL, high D dimer, CRP, high glucose

 

[Instatewaiter]

A 27-year-old man with a history of injection drug use develops a high fever. On physical examination, his temperature is 39.3° C (102.7° F). He has a loud heart murmur. An echocardiogram reveals 1- to 2-cm vegetations on two cusps of his aortic valve. A chest radiograph demonstrates bilateral pulmonary edema. What complication of his disease is he most likely to develop?

A little vague. Again could be one a hundred things. I'm guessing from the size they are going for embolic events. I guess they could be alluding to acute AI given the pulmonary edema and murmur but then he has already developed this so he's technically already developed it.

I have a more advanced one:
27 yo IVDU develops high grade fever and has aortic valve endocarditis inolving his right coronary cusp. He develops pulmonary edema and is transferred to the ICU to be intubated.

EKG shows sinus tachycardia. heart rate 110. QRS duration of 90ms. PR interval 260ms. EKG from 2 days ago shows a HR of 105. QRS Duration of 90ms and PR interval of 200ms.
question 1- what finding will the echo show?
question 2- what procedure do you need to do quickly?

 

[MudPhud20XX]

A little vague. Again could be one a hundred things. I'm guessing from the size they are going for embolic events. I guess they could be alluding to acute AI given the pulmonary edema and murmur but then he has already developed this so he's technically already developed it.

I have a more advanced one:
27 yo IVDU develops high grade fever and has aortic valve endocarditis inolving his right coronary cusp. He develops pulmonary edema and is transferred to the ICU to be intubated.

EKG shows sinus tachycardia. heart rate 110. QRS duration of 90ms. PR interval 260ms. EKG from 2 days ago shows a HR of 105. QRS Duration of 90ms and PR interval of 200ms.
question 1- what finding will the echo show?
question 2- what procedure do you need to do quickly?

so here are the answer choices
A. Calcific aortic stenosis
B. Cardiac myxoma
C. Cerebral mycotic aneurysm
D. Constrictive pericarditis
E. Pulmonary hemorrhagic infarction

 

[MudPhud20XX]

A 33-year-old man is able to run marathon races with a respectable time for his age group. On physical examination his vital signs include heart rate of 70 bpm and blood pressure 120/75 mmHg. There are no remarkable findings. What congenital heart diseases is he most likely to have?

 

[Instatewaiter]

so here are the answer choices
A. Calcific aortic stenosis
B. Cardiac myxoma
C. Cerebral mycotic aneurysm
D. Constrictive pericarditis
E. Pulmonary hemorrhagic infarction

Calcific aortic stenosis occurs over time. So not right
Cardiac myxoma is mass and not related to infective endocarditis.
Hemorrhagic infarcts occur with right sided IE, not left sided.
Constrictive pericarditis doesn't happen with IE

Mycotic aneurysms are a complication from embolic phenomena and are rather common in IE. this is the right answer

 

[MudPhud20XX]

Calcific aortic stenosis occurs over time. So not right
Cardiac myxoma is mass and not related to infective endocarditis.
Hemorrhagic infarcts occur with right sided IE, not left sided.
Constrictive pericarditis doesn't happen with IE

Mycotic aneurysms are a complication from embolic phenomena and are rather common in IE. this is the right answer

mycotic it is... it's actually a misnomer since it's by bacterial infection.

Infective endocarditis can produce septic embolization, and the bacterial growth with inflammation can produce focal destruction of arterial walls.

 

[MudPhud20XX]

a microscopic image of myocardium... what do you think?

 

[lunalight]

correct!, how did you know that this was bicuspid aortic valve?

It's the only congenital heart defect that can be completely silent for most of the patient's life.

 

[Instatewaiter]

a microscopic image of myocardium... what do you think?

Myocarditis

 

[Transposony]

good job.. you are right... how did you know? What was the clue from the question stem?

Question stem points to tamponade + hemataoma (staring @ you) from cut pericardium (most likely postmortem).
Basically, faint heart sounds is a buzzword for pericardial effusion and if you add paradoxical pulse = Cardiac tamponade.

 

[Transposony]

It's the only congenital heart defect that can be completely silent for most of the patient's life.

Slight correction---most of the early part of life since later part of life the valve starts wearing out leading to complications.
This is the reason why they have given the age as 33 yrs.

 

[Transposony]

a microscopic image of myocardium... what do you think?

Lot of blue cells--acute inflammation.
On a closer look, Myofibrils appear broken.
Post MI.

 

[lunalight]

Slight correction---most of the early part of life since later part of life the valve starts wearing out leading to complications.
This is the reason why they have given the age as 33 yrs.

Good catch! Yeah, I forgot about that. BAVs tend to calcify over time, I believe.

 

[MudPhud20XX]

Myocarditis

So here is the question that goes along with the figure.

A 59-year-old woman has had reduced exercise tolerance for the past year. She has chest pain, radiating to her neck, along with diaphoresis, worsening over 6 hours. She goes to the emergency department (ED) 3 days later, when she develops dyspnea. The representative microscopic appearance of her myocardium in the ED is shown in the image. What serum analytes is most likely to be acutely elevated in this woman?

 

[MudPhud20XX]

A 42-year-old healthy woman has been bothered by episodic syncope for the past 3 months. Yesterday she suffered a transient ischemic attack. On physical examination there are no abnormal findings. A chest x-ray is unremarkable. A brain magnetic resonance angiogram shows occlusion of a distal, middle cerebral artery branch on the right. What cardiac mass lesions is this woman most likely to have?

 

[mcloaf]

Lot of blue cells--acute inflammation.
On a closer look, Myofibrils appear broken.
Post MI.

I agree, lack of nuclei w/in cardiac myocytes is a giveaway. Elevated trops.

 

[Transposony]

A 42-year-old healthy woman has been bothered by episodic syncope for the past 3 months. Yesterday she suffered a transient ischemic attack. On physical examination there are no abnormal findings. A chest x-ray is unremarkable. A brain magnetic resonance angiogram shows occlusion of a distal, middle cerebral artery branch on the right. What cardiac mass lesions is this woman most likely to have?

Left atrial myxoma

 

[Instatewaiter]

So here is the question that goes along with the figure.

A 59-year-old woman has had reduced exercise tolerance for the past year. She has chest pain, radiating to her neck, along with diaphoresis, worsening over 6 hours. She goes to the emergency department (ED) 3 days later, when she develops dyspnea. The representative microscopic appearance of her myocardium in the ED is shown in the image. What serum analytes is most likely to be acutely elevated in this woman?

And this is why I'm not a pathologist.

It is also why step 1 is a stupid exam. Many of the questions are clinically useless. You'd never in a million years get a myocardial biopsy in a patient peri-MI. Troponin would also be positive in myocarditis.

 

[MudPhud20XX]

A 45-year-old woman with headaches for 5 months goes to her physician. On physical examination her blood pressure is 160/100 mmHg. No other abnormalities are noted. She is given antihypertensive therapy. Her blood pressure remains in good control for a year, but then she develops severe headaches for 2 days. Her blood pressure is now recorded at 250/150 mmHg. Laboratory studies show a serum urea nitrogen of 4.5 mg/dL with creatinine of 49 mg/dL. What pathologic lesions involving her arterial circulation is most likely to accompany these findings?

 

[MudPhud20XX]

Left atrial myxoma

correct.

Such a tumor (probably not a true neoplasm) is rare, though it is the most common primary cardiac tumor in adults. The myxoma can produce a “ball valve” effect and episodically occlude the mitral valve. Portions of the myxoma can break off and embolize, which is the likely etiology for her cerebrovascular event.

 

[MudPhud20XX]

diff. diagnosis?

 

[Transposony]

................... creatinine of 49 mg/dL. ..............

Something not right here.

 

[Transposony]

diff. diagnosis?

Hypertrophic cardiomyopathy

 

[Gdl88]

A 45-year-old woman with headaches for 5 months goes to her physician. On physical examination her blood pressure is 160/100 mmHg. No other abnormalities are noted. She is given antihypertensive therapy. Her blood pressure remains in good control for a year, but then she develops severe headaches for 2 days. Her blood pressure is now recorded at 250/150 mmHg. Laboratory studies show a serum urea nitrogen of 4.5 mg/dL with creatinine of 49 mg/dL. What pathologic lesions involving her arterial circulation is most likely to accompany these findings?

Aortic coarctation

 

[lunalight]

A 45-year-old woman with headaches for 5 months goes to her physician. On physical examination her blood pressure is 160/100 mmHg. No other abnormalities are noted. She is given antihypertensive therapy. Her blood pressure remains in good control for a year, but then she develops severe headaches for 2 days. Her blood pressure is now recorded at 250/150 mmHg. Laboratory studies show a serum urea nitrogen of 4.5 mg/dL with creatinine of 49 mg/dL. What pathologic lesions involving her arterial circulation is most likely to accompany these findings?

Fibrinoid necrosis

 

[Instatewaiter]

It's the only congenital heart defect that can be completely silent for most of the patient's life.

Not completely true. ASDs and small VSDs can be silent.

A 45-year-old woman with headaches for 5 months goes to her physician. On physical examination her blood pressure is 160/100 mmHg. No other abnormalities are noted. She is given antihypertensive therapy. Her blood pressure remains in good control for a year, but then she develops severe headaches for 2 days. Her blood pressure is now recorded at 250/150 mmHg. Laboratory studies show a serum urea nitrogen of 4.5 mg/dL with creatinine of 49 mg/dL. What pathologic lesions involving her arterial circulation is most likely to accompany these findings?

A lab tech having a stroke?

RAS

 

[MudPhud20XX]

Not completely true. ASDs and small VSDs can be silent.




A lab tech having a stroke?

RAS

so here are the answer choices.

A. benign nephrosclerosis
B. cystic medical necrosis
C. endaortits
D. fibromuscular dysplasia
E. Hyperplastic arteriolosclerosis
F. monckberg medial calcific sclerosis
G. renal artery thrombosis

 

[MudPhud20XX]

Hypertrophic cardiomyopathy

so here is with the clinical vignette.

A 25-year-old woman has had a low-grade fever and chills for 3 weeks. On physical examination a shrill systolic murmur is present. An echocardiogram reveals a ventricular septal defect. What form of endocarditis is she most likely to have?

 

[MudPhud20XX]

what do you guys see?

 

[Transposony]

what do you guys see?

Hyaline arteriolosclerosis.

 

[Transposony]

so here are the answer choices.

A. benign nephrosclerosis
B. cystic medical necrosis
C. endaortits
D. fibromuscular dysplasia
E. Hyperplastic arteriolosclerosis
F. monckberg medial calcific sclerosis
G. renal artery thrombosis

G. renal artery thrombosis

 

[Instatewaiter]

so here are the answer choices.

A. benign nephrosclerosis
B. cystic medical necrosis
C. endaortits
D. fibromuscular dysplasia
E. Hyperplastic arteriolosclerosis
F. monckberg medial calcific sclerosis
G. renal artery thrombosis

FMD causing RAS.

 

[MudPhud20XX]

FMD causing RAS.

sorry guys... the figure had nothing to do with my answer choices.. I messed up. here it is

A 45-year-old woman with headaches for 5 months goes to her physician. On physical examination her blood pressure is 160/100 mmHg. No other abnormalities are noted. She is given antihypertensive therapy. Her blood pressure remains in good control for a year, but then she develops severe headaches for 2 days. Her blood pressure is now recorded at 250/150 mmHg. Laboratory studies show a serum urea nitrogen of 4.5 mg/dL with creatinine of 49 mg/dL. Which of the following pathologic lesions involving her arterial circulation is most likely to accompany these findings?

A. benign nephrosclerosis
B. cystic medical necrosis
C. endaortits
D. fibromuscular dysplasia
E. Hyperplastic arteriolosclerosis
F. monckberg medial calcific sclerosis
G. renal artery thrombosis

 

[MudPhud20XX]

Hyaline arteriolosclerosis.

yup correct.... pink, glasy arterial wall thickening with luminal narrowing seen in benign hypertension, diabetes, and aging

 

[MudPhud20XX]

what do you guys see?

 

[Transposony]

what do you guys see?

Heart showing tumor. The only tumor of heart I can think of is a rhabdomyoma.

 

[MudPhud20XX]

Heart showing tumor. The only tumor of heart I can think of is a rhabdomyoma.

excellent. Cardiac rhabdomyomas are rare, but they can be seen in the pediatric age group. When large, they can compromise cardiac function. Some are related to the uncommon phakomatosis known as tuberous sclerosis, but other abnormalities such as renal angiomyolipoma and cerebral hemispheric hamartomatous lesions called tubers are usually present as well.