Pre-session Number2(Trial-2 /// 8July2013)

Case Review CourseTrial-6 / 12Mordad1392

And He knows whatever there is,on the earth and in the

sea…Not even A LEAF falls,

but he knows it…

An’aam- 59

JVP:Seen in Cause

Giant a waves

Pulmonary hypertensionPulmonary stenosisTricuspid stenosis

Increased resistance to ventricular filling

Cannon a waves

Complete heart block

Atrial contraction against a closed tricuspid valve

Large v wave

Tricuspid regurgitation

Steep y descent

Tricuspid regurgitationConstrictive pericarditis

Steps for assessing the JVP:• Make the patient comfortable. Raise the head of the bed or examining table to about 30°. Turn the

patient's head slightly away from the side you are inspecting.• Find the internal jugular venous pulsations.• If necessary, raise or lower the head of the bed until you can see the oscillation point or meniscus

of the internal jugular venous pulsations in the lower half of the neck.• Focus on the right internal jugular vein. • Identify the highest point of pulsation in the right internal jugular vein. Extend a long rectangular

object or card horizontally from this point and a centimeter ruler vertically from the sternal angle, making an exact right angle. Measure the vertical distance in centimeters above the sternal angle where the horizontal object crosses the ruler. This distance, measured in centimeters above the sternal angle or the atrium, is the JVP.

• Venous pressure measured at greater than 3 cm or possibly 4 cm above the sternal angle, or more than 8 cm or 9 cm in total distance above the right atrium, is considered elevated above normal.

Case:

A 37-year-old woman presents to her primary care physician complaining of progressive fatigue and shortness of breath over the past 3 months. She also reports that her socks and shoes do not fit the way they used to and that she fainted a few weeks ago for the first time in many years. She also states that she is more comfortable sitting than lying down. She denies any recent illness but is suffering from joint pain sometimes.

In physical examination she has jugular venous distention, which increases with inspiration. The physician also found some rashes on her lower extremities which she remembered they’re sometimes itchy and painful.

Her blood pressure is 134/87 mm Hg, respiratory rate is 17/min, pulse is 96/min, and temperature is 37.2 C (98.9 F). She also has decreased breath sounds bilaterally at the bases. An ECG shows decreased QRS voltage. An echocardiogram shows a thick left ventricle. Chest x-ray shows granulomas in the base of the lungs.

Differential Diagnosis:

(A) Aortic stenosis(B) Cardiac tamponade(C) Hypertensive heart disease(D) Pericarditis(E) Restrictive cardiomyopathy

Answer:The correct answer is E. This is a classic description of restrictive

cardiomyopathy (RCM). RCM is almost always associated with infiltrative diseases such as amyloidosis, sarcoidosis, or hemochromatosis. These conditions restrict left ventricle filling, causing decreased output and compliance, and increased filling pressure. Consequently, patients begin to experience congestive heart failure symptoms. Here, this patient complains of dyspnea (positional and with exertion), syncope, and peripheral edema. She also has the classic Kussmaul’s sign (increased jugular venous distension with inspiration) that, although it is not specific for this condition, contributes to making the diagnosis.

The combination of the echocardiogram and ECG signs listed are also classic for making the diagnosis. Treatment of this condition is to control the underlying cause (e.g., iron chelation for hemochromatosis), diuretics, angiotensin- converting enzyme inhibitors, and nitrates.

Answer A is incorrect. Aortic stenosis (AS) is important because it is currently the leading indication for valve replacement. AS usually presents in older individuals (age ≥ 60 years) and features the classic triad of angina, syncope, and heart failure. Physical examination reveals pulsus parvus et tardus (small and slowly rising carotid pulse).

Answer B is incorrect. Cardiac tamponade usually presents as subacute dyspnea, fatigue, or anxiety that waxes and wanes. It is often associated with end-stage renal disease or other conditions that may involve the pericardium. Physical examination is characterized by Beck’s triad (jugular venous distention, hypotension, and muffled heart sounds). It can be caused by pericarditis.

Answer C is incorrect. This patient’s blood pressure is within normal limits, and there is low suspicion for hypertensive heart disease. However, hypertensive heart disease can manifest as concentric and eventually dilated heart failure. On echocardiography, a dilated heart with an elevated end-diastolic volume and low ejection fraction would be detected. Arrhythmias and angina may accompany a hypertensive crisis.

Answer D is incorrect. Pericarditis is most often confused with restrictive cardiomyopathy (RCM). To differentiate these two conditions, first look at the history. Pericarditis patients will likely have had a viral infection 1–2 weeks preceding the complaints. Physical examination is also helpful because pericarditis patients will often have a pericardial knock or rub and a prominent S4 heart sound. On biopsy, pericarditis samples will be normal, and RCM will be abnormal.

:Mini-cases

1.

• Pneumonia• Pulmonary embolism• Costochondritis• MI

Differential diagnosis:

70 yo F presents with acute onset of shortness of breath at rest and pleuritic chest pain.

She also presents with tachycardia, hypotension, tachypnea, and mild fever. She is recovering from hip replacement surgery.

2.

• Crohn’s disease• Proctitis• Hemorrhoids• Ulcerative colitis

33 yo F presents with rectal bleeding and diarrhea for the past week. She has had lower abdominal pain and

tenesmus for several months .

Differential diagnosis:

3.

• Bladder cancer• Renal cell carcinoma• Glomerulonephritis• UTI

57 yo male had 1 episode of painless hematuria yesterday morning. He has no fever, no abdominal or flank pain, and no dysuria. No history of renal stones. He has a 2-year history of straining on urination, polyuria, nocturia, weak urinary stream, and dribbling. No nausea, vomiting, diarrhea, or constipation. No change in appetite or weight loss. No previous similar episodes.

Differential diagnosis:

4.12 yo F presents with pancarditis, fever and arthralgia.The arthralgia is temporary migrating, usually starting in the legs and migrating upwards. She recovered from a respiratory infection 3 weeks ago.

Differential diagnosis: • Myocarditis • Leukemia • Rheumatic fever• Kawasaki disease

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