CH. 69 INFECTIVE ENDOCARDITIS AND VALVULAR HEART DISEASE

INFECTIVE ENDOCARDITIS

100

THIS VALVULAR ABNORMALITY IS THE MOST COMMON PREDISPOSING ABNORMALITY FOR IE IN DEVELOPED COUNTRIES

MITRAL VALVE PROLAPSE

CLASSICALLY, A VEGETATION WILL RESULT IN A STERILE THROMBUS UPON WHICH MICROORGANISMS ADHERE AND COLONIZE

200

TRUE/FALSE, MANY PATIENTS SEEN EARLY DURING THE BACTEREMIC PHASE OF ILLNESS DO NOT HAVE A CARDIAC MURMUR AND ARE INDISTINGUISHABLE FROM THE LARGE POPULATION OF PATIENTS WHO COME TO THE EMERGENCY DEPARTMENT WITH A FEBRILE VIRAL ILLNESS

TRUE

SYMPTOMS ARE NONSPECIFIC, MOST PATIENTS WILL COMPLAIN OF INTERMITTENT FEVERS AND MALAISE

CLASSIC TRIAD OF FEVER, ANEMIA AND HEART MURMUR IS RARE

300

SOME PATIENTS WILL HAVE COMPLICATIONS OF IE AS PRESENTING COMPLAINTS. THE MOST COMMON AND SEVERE ARE ____ AND ____

CHF AND NEUROLOGIC EVENTS

CONSIDER IE IN SETTING OF CVA SYMPTOMS AND FEVER

CVA MAY RESULT FROM SEPTIC EMBOLI OR RUPTURED MYCOTIC ANEURYSMS

MAY ALSO PRESENT WITH SEPTIC PE OR VERTEBRAL OSTEOMYELITIS

400

UNEXPLAINED FEVER IN THIS PATIENT POPULATION SHOULD RASE CONCERN FOR IE

IV DRUG USERS

WHICH SIDE OF THE HEART IS MORE COMMONLY INVOLVED IN THESE PEOPLE?

500

NAME THESE THINGS.

SPLINTER HEMORRHAGE, ROTH SPOTS, JANEWAY LESIONS, OSLER'S NODE

THESE FINDINGS ARE RARE

30% OF PEOPLE HAVE SPLENOMEGALY

CONJUNCTIVAL AND RETINAL HEMORRHAGES ARE ALSO SEEN

600

THIS AMOUNT OF BLOOD CULTURES IS RECOMMENDED WITH THE FIRST AND LAST DRAWN ___ APART FROM ONE ANOTHER

2 SEPARATE CULTURES DRAWN AT LEAST AN HOUR APART FROM SEPARATE SITES

HOW MANY CULTURES SHOULD YOU GET IF THE PATIENT HAS A PROSTHETIC VALVE OR PACEMAKER? WHY?

700

NAME 2 MAJOR DUKE CRITERIA FOR IE

800

TRUE/FALSE, ED PROCEDURES (SUTURING, INTUBATION, CENTRAL LINES, DELIVERIES, FOLEY CATHETER PLACEMENT (IN ABSENCE OF INFECTION) REQUIRE ANTIBIOTIC PROPHYLAXIS FOR PATIENTS WITH PROSTHETIC VALVES

FALSE

900

ONE EXCEPTION IS MADE IN THE TEXT REGARDING ANTIBIOTIC PROPHYLAXIS FOR ED PROCEDURES IN PATIENTS WITH HIGH RISK CONDITIONS FOR IE. WHAT IS THE PROCEDURE AND WHAT IS THE RECOMMENDATION?

CUTANEOUS ABSCESS DRAINAGE

GIVE VANCOMYCIN 15MG/KG 1 HOUR PRIOR TO PROCEDURE

"HIGH RISK POPULATIONS":

HX OF ENDOCARDITIS, CONGENITAL HEART DEFECT, IV DRUG USE, PROSTHETIC HEART VALVE, PACEMAKER/DEFIBRILLATOR, DIALYSIS, RECENT HOSPITALIZATION WITH CENTRAL LINE OR LONG TERM IV ACCESS

RHEUMATIC FEVER

100

COMPLICATION OF WHAT TYPE OF INFECTION

STREPTOCOCCAL PHARYNGITIS

ACUTE RHEUMATIC FEVER WILL DEVELOP 1-5 WEEKS AFTER INITIAL PHARYNGITIS

FEVER GENERALLY PRESENT DURING ACUTE PHASE OF ARF WITH ARTHRITIS, CARDITIS, CHOREA (RARELY), SUBCUTANEOUS NODULES, ERYTHEMA MARGINATUM (TRUNK AND PROXIMAL EXTREMITIES)

200

THIS IS THE MOST COMMON MANIFESTATION OF ACUTE RHEUMATIC FEVER

MIGRATORY POLYARTHTRITIS

CLASSICALLY AFFECTS LARGE JOINTS: KNEES, ANKLES, ELBOW, WRIST

PAIN OUT OF PROPORTION TO EXAM

STERILE INFLAMMATORY SYNOVIAL FLUID IT TAPPED

300

THIS IS THE MOST COMMON VALVE AFFECTED BY ACUTE RHEUMATIC FEVER

MITRAL VALVE

MITRAL REGURGITATION WILL DEVELOP

400

ERYTHEMA MARGINATUM

CUTANEOUS FINDINGS OF ARF INCLUDE THIS AND PEA SIZED NONTENDER SUBQ NODULES ON EXTENSOR SURFACES

500

NAME 2 MAJOR JONES CRITERIA FOR ARF

PRESENCE OF 2 MAJOR OR 2 MINOR PLUS 1 MAJOR CRITERIA ALONG WITH EVIDENCE OF RECENT STREP INFECTION INDICATE HIGH PROBABILITY OF ARF

600

TRUE/FALSE, TREATMENT FOR ARF IS SAME AS THAT FOR STREP PHARYNGITIS

TRUE

PENICILLIN FIRST LINE

VALVULAR DISEASE

100

THE MOST COMMON COMPLICATION OF THIS MURMUR IS AFIB

MITRAL STENOSIS

WHY?

EXERCISE INTOLERANCE AND EXERTIONAL DYSPNEA ARE EARLY SYMPTOMS

PATIENTS WILL EVENTUALLY DEVELOP SIGNS OF HEART FAILURE

A LOUD S1 AND OPENING SNAP IN EARLY DIASTOLE ACCOMPANIED BY A LOW PITCHED RUMBLING DIASTOLIC MURMUR  

200

IN THE ACUTE PHASE, THIS VALVULAR ABNORMALITY PRESENTS AS A "TRUE EMERGENCY". IT IS ALSO THE MOST COMMON VALVE ABNORMALITY WORLDWIDE. WHAT IS IT?

MITRAL REGURGITATION

MAY RESULT FROM RUPTURE OF THE CHORDAE TENDINEAE, PAPILLARY MUSCLE DYSFUNCTION DUE TO ISCHEMIA, OR VALVE LEAFLET PERF FROM ENDOCARDITIS OR TRAUMA

IN THE ACUTE PHASE PATIENT'S DEVELOP FULMINANT PULMONARY EDEMA AND CARDIOGENIC SHOCK

NEW HARSH, MIDSYSTOLIC MURMUR

WHAT WILL YOUR ED TREATMENT BE?

WHAT PRESSOR WOULD YOU USE?

IF SUSPECTED EMERGENT ECHO AND CATH IS INDICATED TO ASSESS THE URGENCY FOR SURGERY

300

THIS VALVULAR ABNORMALITY WILL PROGRESS FROM ANGINA, TO EXERTIONAL SYNCOPE, THEN TO HEART FAILURE

AORTIC STENOSIS

REMEMBER THESE PATIENTS ARE VERY PRELOAD DEPENDENT WITH LITTLE CARDIAC RESERVE

TREATMENT FOR DECOMPENSATED AORTIC STENOSIS RELIES ON FLUID RESUSCITATION, BLOOD TRANSFUSION IF INDICATED, MAINTENANCE OF A SINUS RHYTHM, AVOIDANCE OF VASODILATORS, DIURETICS AND INOTROPIC AGENTS

WHAT PRESSOR WOULD YOU USE IF NEEDED? WHY?

ANGINA RESULTS FROM DECREASED BLOOD SUPPLY FROM REDUCTION IN PERFUSION PRESSURE

SYNCOPE RESULTS FROM FIXED CARDIAC OUTPUT

400

ONE OF OUR FREQUENT FLIERS KNOWN TO PARTAKE IN BOOGER SUGAR, METH AND MARLBORO REDS PRESENTS WITH CHEST AND BACK PAIN HE DESCRIBES AS A TEARING SENSATION. HE IS IN RESPIRATORY DISTRESS AND HYPOXIC WITH RALES ON EXAM. A TECH STICKS AN EKG IN YOUR FACE WHILE YOU ARE TRYING TO PERFORM YOUR PHYSICAL EXAM AND YOU NOTICE DIFFUSE ST DEPRESSIONS. WHAT DO YOU SUSPECT?

AORTIC DISSECTION WITH EXTENSION INTO THE AORTIC ROOT CAUSING DEMAND ISCHEMIA AND CARDIOGENIC SHOCK

WOULD AN IABP HELP? WHY OR WHY NOT?

WHAT DOES THIS PERSON NEED?

500

THIS GENERALLY BENIGN VALVULAR ABNORMALITY IS COMMONLY ASSOCIATED WITH CONNECTIVE TISSUE DISORDERS

MITRAL VALVE PROLAPSE

600

TRUE/FALSE, PROSTHETIC VALVE PATIENTS WITH NO OBVIOUS SOURCE OF FEVER SHOULD BE CONSIDERED FOR ADMISSION, SPECIFICALLY WITHIN 60 DAYS OF SURGERY

TRUE

PROSTHETIC VALVE ENDOCARDITIS SHOULD BE CONSIDERED IN THIS SETTING

700

WHAT VALVE ABNORMALITY CAUSES THIS?  BONUS NERD POINTS FOR WHAT IT'S CALLED.

AORTIC REGURGITATION

MUSSET'S SIGN

OTHER SIGNS INCLUDE RAPIDLY RISING AND FALLING CAROTI DPULSE, NAIL BED PULSATIONS, A BRUIT OVER THE FEMORAL ARTERY