Cardiovascular pathology clinical cases::part 2 :: مناقشة حالات سريرية

د.اسراء مهدي السوداني · 03-06-2010, 02:51 PM

NEW CASES

5- A 17-year-old girl is brought to the physician because she remains short in stature for her age. She has not shown any changes of puberty. On physical examination her vital signs include T 37 C, RR 18/minute, P 75/minute, and BP 165/85 mm Hg. She has a continuous murmur heard over both the front of the chest as well as her back. Her lower extremities are cool with poor capillary filling. She has a webbed neck. A chest radiograph reveals a prominent left heart border, no edema or effusions, and rib notching. Which of the following cardiovascular abnormalities is she most likely to have?
A Shortening and thickening of chordae tendineae of the mitral valve
B Constriction of the aorta past the ductus arteriosus
C Supravalvular narrowing in the aortic root
D Lack of developme

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فإن كنت مشترك مسبقا معنا فقم بتسجيل دخول بعضويتك للمتابعة وإن لم تكن فيمكنك تسجيل عضوية جديدة مجانا ً ( من هنا )

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dr:mahmoud · 03-06-2010, 06:02 PM

Regarding case No.8
All signs and symptoms ( fever , splenomegaly, splinter hemorrhages of fingernails, murmurs) state that the patient is suffering from infective endocarditis due to streptococcal infection (the patient may be drug addict because of his abnormal mental status)so there will be elevated anti-streptolysin O >250 I.U
Other choices :high CK is characteristic for MI
Elevated Coxsackie B viral titer is indicator for viral infection but not for bacterial
Increased urinary free catecholamines is seen in hypertensive patient and patient with phaeochromocytoma
Positive urine screen for opiates :
At the first time I thought that this is the right choice (because of the abnormal mental status) but I think that high ASOT is more appropriate
Anyway I am ready for any corrections

Dr tariq · 03-06-2010, 06:58 PM

بسم الله الرحمن الرحيم

Regarding case 5

All the manifestations that mentioned in the case indicate that the patient girl may has a Turner's syndrome (short stature, webbed neck, and hypertension) and Turner's syndrome usually coincide with cardiovascular anomalies especially aortic coarctation and bicuspid aortic valve, so I tend to choose the second choice (Constriction of the aorta past the ductus arteriosus) as a correct answer of this case.i

Also the prominent left border of the heart that is revealed in the chest radiograph supports my choice, because as we know that the coarctation of the aorta causes an enlargement of the left ventricle.i

The first choice is excluded because the shortening and thickening of the chordae tendineae lead to mitral insufficiency, and this cannot cause elevation in blood pressure.i

The third choice is excluded because in Turner's syndrome the coarctation of the aorta usually occurs just distal to the left subclavian artery.i

The fourth and fifth choices are excluded because they not occur in case of Turner's syndrome.i

PAST · 03-06-2010, 09:00 PM

first let's think about case num(6)in this way :
1- it is an autoimmune disease looking at the ANA titre
2- " An echocardiogram reveals small vegetations on the mitral valve and adjacent ventricular endocardium. " suggests the case as STERILE ENDOCARDITIS
3-The malar skin rash.
4- Non-suggestive signs and symptoms including the malaise

From all of the above i believe that this is a patient with SLE and the sounds heard in ascultation are due the mitral valve regurgitation due to (LIBMAN-SACKs Endocarditis )*

Dr tariq · 03-06-2010, 09:08 PM

Regarding case 6

I am with you PAST, and you are faster than me because I was writing this article at the same time you was writing your ones, but you put it before me.i

Each, the first, fourth, and fifth choices are excluded because they don’t give us a positive ANA test.i

Now we have two choices the second (progressive sclerosis) and the third (SLE), I know that SLE cause malar skin rashes, so I tend to choose it as the correct answer to this case.i

Dr tariq · 03-06-2010, 09:20 PM

Regarding case 7

The fourth choice is excluded because the pulmonary stenosis doesn’t cause pulmonary artery enlargement.i
i
the second, third, and fifth choices are excluded because they don't cause cardiac enlargement.i

I think that The correct answer to this case is the aortic stenosis.i

i[Because the presence of aortic stenosis this lead to congestion in the left ventricle and this will reflected backward to cause pulmonary congestion and pulmonary hypertension, also aortic coarctation cause decrease in systemic blood flow and this lead to stasis of the blood and thromboembolism ]i

i

josef.alkhouri · 03-07-2010, 11:35 AM

i can see that dr.tariq have the exact diagnosis of mine. i just want to corroborate his correct answer by adding that the turner syndrom girl has a rib notching ,which medically is defined, as A [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل] [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل] in the lower [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل] of one or more [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل] [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل] caused by enlarged [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل] [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل](due to the compensentory collateral circulation), most often sign of [فقط الأعضاء المسجلين والمفعلين يمكنهم رؤية الوصلات . إضغط هنا للتسجيل] (answer b). the cold lower extremities with poor capillary filling can also be explained by the same collateral circulation which may direct the blood a slight bit away from the real circulation conducted by the aorta.

Dr.tariq · 03-11-2010, 01:07 PM

السلام عليكم و رحمة الله و بركاته

the answer of case No.7 is wrong can anybody correct!i

د.اسراء مهدي السوداني · 03-14-2010, 03:25 AM

Right answers are
case 5 is B
case 6 is C
case 7 is C
case 8 is B

Discuss more for wrong answers.. Good Luck

josef.alkhouri · 03-16-2010, 07:45 PM

A. Coarctation of the aorta has been discussed above as a right answer so we all know what it causes.
B. Teratology of fallot: is one of the cyanotic or early cyanotic group. Characterized by Ventricular septal defect(VSD), overriding of the aorta on VSD, pulmonary stenosis and Rt ventricular hypertrophy. Cardiac enlargement is positive in our case(case number 7). it is not mentioned if it is only a Rt ventricular hypertrophy where the heart would look like a boot. Teratology of fallot includes VENTRICULAR SEPTAL DEFECT ( which is the right answer) so how can we exclude this from being a right answer ( please Dr. israa enlighten us).
C. Pulmonic stenosis, syn; pulmonary stenosis??? This would have given the patient a blue colored skin (cyanosis).
D. Dextrocardia: medically defined as Displacement of the heart to the right, either as dextroposition (overriding of the aorta on VSD), with simple displacement to the right, or as cardiac heterotaxia, with complete transposition of the right and left chamber.
However dextrocardia and heterotaxia are exluded because serum troponin I does not become elvated in these cases since serum troponin is recognized as a sensitive and specific marker for cardiac injury. It is more accurate than creatine kinase-MB concentrations for the diagnosis of myocardial infarction (MI) and provides more useful prognostic information. It also permits the early identification of those with an increased risk of death in patients with acute coronary syndromes Serum troponin I.
josef alkhouri / 3rd year medicine b1

Cardiovascular pathology clinical cases::part 2 :: مناقشة حالات سريرية

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