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* cvs1
 #375077  
  showman - 01/06/09 14:19
 
  A 38-year-old healthy Caucasian man is brought to the emergency department because of sudden onset of shortness of breath and diaphoresis. He denies fever, chills, cough or abdominal pain. He has no other medical problems. He had surgery for bilateral inguinal hernia when he was 16. He does not use tobacco, alcohol or illicit drugs. He takes no medication and has no known drug allergies. His blood pressure is 110/60 mm Hg, pulse is 116/min and respirations are 28/min. He is in marked respiratory distress. Pallor and diaphoresis are noted. His skin is velvety and has multiple scars. On auscultation of the heart, an early, decrescendo, systolic murmur at the cardiac apex is heard; the murmur decreases with Valsalva maneuver, and increases with the grip maneuver, radiating to the axilla. The first sound is barely audible; the second heart sound is normal. A fourth heart sound is also present. There are bilateral crackles in both lungs. Jugular venous distention and hepatojugular reflux are present. The abdomen is soft, non-tender and non-distended. The neurologic examination reveals no abnormalities. The initial EKG shows sinus tachycardia with occasional premature ventricular complexes. The chest x-ray reveals no cardiomegaly, but bilateral alveolar infiltrates and hilar prominence are present.
Item 1 of 2
Which of the following is the most likely cause of his condition?
A) Acute myocardial infarction
B) Rupture of chordae tendineae
C) Pulmonary embolism
D) Infective endocarditis
E) Papillary muscle rupture
 
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* Re:cvs1
#1617235
  kaps - 01/06/09 14:24
 
  bb  
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* Re:cvs1
#1617236
  showman - 01/06/09 14:24
 
  The patient presents with signs and symptoms of acute heart failure. His EKG findings reveal occasional premature ventricular complexes (PVC); there are no signs of ischemia or ventricular hypertrophy. His pathologic murmur (systolic murmur that is heard in the apex, radiates to the axilla, increases with the grip maneuver, and decreases with Valsalva) is characteristic of mitral regurgitation, which may lead to acute heart failure. Acute mitral regurgitation is usually characterized by a soft, decrescendo systolic murmur (can be early, midsystolic or holosystolic), a decreased first heart sound, and the presence of a fourth heart sound. Due to the acute nature of this condition, there is no evidence of left ventricular hypertrophy in the electrocardiogram or the chest x-ray.
The four common causes of acute heart failure are papillary muscle rupture, infective endocarditis, rupture of chordae tendineae, and chest wall trauma with compromise of the valvular apparatus. The most common cause of isolated, severe acute mitral regurgitation in adults is rupture of chordae tendineae with or without associated myxomatous disease. The diagnosis is confirmed by echocardiography.
(Choice A) Myocardial infarction can be complicated by acute mitral regurgitation when there is rupture of the papillary muscle; however, this patient does not have evidence of ischemia in the EKG.
(Choice C) Patients with pulmonary embolism can develop acute cor pulmonale; however, in such a setting, the EKG will show right axis deviation, right bundle branch block or both. The above patient clearly has acute pulmonary edema.
(Choice D) The patient does not have fever or risk factors for bacterial endocarditis.
(Choice E) Spontaneous papillary muscle rupture usually presents in elderly people who have acute chest pain or as a complication of myocardial infarction. None of these are present here.


bbbbbbb is rt ans
 
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