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Category: Cardiology--->Pulmonary Hypertension And Pericardium
Page: 4

Question 16#Print Question

A 39-year-old patient with no prior medical visits presents with cardiac tamponade and undergoes urgent pericardiocentesis. He is from sub-Saharan Africa and has never been seen by a physician before—reports feeling progressively ill for the past month and brought to the hospital after syncopal episode today. Fluid analysis is performed and listed below:

  • Gram stain: no gram-positive/gram-negative bacteria noted Peripheral cell count: normal (peripheral cell count <10 × 109 cells/L) Pericardial fluid differential (lymphocyte/neutrophil): >1.0 (monocytes present as well)
  • Protein: elevated
  • hsCRP: markedly elevated
  • Lactate dehydrogenase (LDH): elevated (>2.0 times peripheral LDH level)
  • Adenosine deaminase (ADA): >40 U/L 
  • Interferon gamma: >50 pg/mL
  • Glucose: low
  • Culture and cytology/acid fast staining: pending

The most likely etiology for the effusion would be:

a. Tuberculous pericarditis
b. Endemic malignancy (i.e., Epstein-Barr virus–associated Burkitt’s) with metastatic spread
c. Malarial (Plasmodium vivax)
d. Unable to determine—require pericardial biopsy to confirm


Question 17#Print Question

A 47-year-old man with constrictive pericarditis is undergoing an echocardiogram for follow-up. The sonographer asks you to explain the difference between the annulus reversus and annulus paradoxus phenomena.

Which of the following statements is correct?

a. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (E′ septal > E′ lateral) and annulus paradoxus refers to inverse correlation of E/E’ and LV end-diastolic pressure
b. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (A′ septal > A′ lateral) and annulus paradoxus refers to inverse correlation of E/E′ and LV end-diastolic pressure
c. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (E′ septal < E′ lateral) and annulus paradoxus refers to positive correlation of E/E′ and LV end-diastolic pressure
d. Annulus reversus refers to reversal of septal and lateral mitral tissue Doppler velocities (A′ septal < A′ lateral) and annulus paradoxus refers to a positive correlation of E/E′ and LV end-diastolic pressure


Question 18#Print Question

A 51-year-old male patient is admitted to the hospital with anasarca and progressive dyspnea and functional limitation. He has a prior history of coronary artery bypass grafting and post-pericardiotomy syndrome with relapsing pericarditis that has likely advanced to constrictive physiology (despite slow taper steroid therapy), given his presenting symptoms and physical examination findings. During the admission he is aggressively diuresed with IV diuretics with improvement in his renal and liver function, as well as symptom improvement (edema and dyspnea). He is unable to go for a magnetic resonance imaging (MRI) for further assessment (prior metallic implant in his spine for scoliosis) and his echocardiogram images are technically difficult due to his distorted spine and prior cardiac surgery. He is referred for dual transducer cardiac catheterization for hemodynamic evaluation of right- and left-sided pressures as part of his diagnostic workup. The catheterization laboratory team begins the procedure and calls you to discuss the case. They note a sinus rhythm at 90 bpm with occasional premature ventricular contraction and a central venous pressure of 4 mmHg and nonelevated end-diastolic pressures at the beginning of the study (due to recent diuresis); they are unable to elucidate diastolic equalization of pressures, significant “dip and plateau,” or respiratory discordance of the ventricular pressure waveforms. 

A potential mechanism for the discordant catheterization findings would be:

a. Lack of preload due to overdiuresis
b. Borderline tachycardia and ectopy preventing accurate analysis
c. Presence of only mild constrictive physiology
d. Presence of restrictive cardiomyopathy and physiology


Question 19#Print Question

A 32-year-old white man presented initially with low-grade fever, cough, and pleuritic chest pain. He was found on ECG to have diffuse ST-segment elevation. A transthoracic echocardiogram (TTE) revealed a large pericardial effusion, and serologies were positive for coxsackievirus B infection. He was diagnosed with acute viral pericarditis and treated with indomethacin. He returns 4 weeks later for follow-up and states that he no longer has any pain, but he notes some mild ankle swelling. His ECG is normal. A repeat TTE shows resolution of the effusion but new findings consistent with mild constriction.

What is the next step in managing this patient?

a. Obtain cardiac MRI to better assess the pericardium
b. Have a cardiothoracic surgical consultation for pericardiectomy
c. Reassure the patient and observe him over the next 3 months for worsening of symptoms
d. Start a course of steroids


Question 20#Print Question

A 45-year-old woman with a history of treated carcinoma of the breast presents to the local emergency department with a few days of severe chest pain. In the emergency department, she appears ill and pale and in moderate discomfort. Her BP is 135/60 mmHg; her respiratory rate is 24 breaths per minute; her HR is 82 bpm; and her temperature is 100.8°F. The resident on call reads her chest X-ray (CXR) as unremarkable. Her ECG is shown in Figure below.

What is the most reasonable next step? 

a. Give aspirin and nitroglycerin and prepare to administer thrombolytics
b. Call the cardiac intervention team and rush the patient to the catheterization laboratory for emergency coronary intervention
c. Give a nonsteroidal anti-inflammatory medication
d. Discharge the patient and refer her for a gastroenterology follow-up as an outpatient




Category: Cardiology--->Pulmonary Hypertension And Pericardium
Page: 4 of 8