CV module TBL Session Group Application Activity

Case #1
A 68 year old man is brought to the emergency department by
ambulance after having a syncopal episode while jogging. He states
that he was running when he suddenly passed out. He denies any
palpitations, chest pain, or dizziness preceding this event. He does
report that for the past few weeks, he has had some substernal chest
pain when exercising, but that has been relieved with rest. He denies
any shortness of breath, leg swelling, or orthopnea. He denies any
significant past medical history but has not been to a doctor in over 10
years because he has felt overall well during this time. He denies any
significant family history for cardiovascular disease. He also denies
any tobacco, drug, or alcohol use. On physical examination, his
temperature is 37 degrees Celsius, blood pressure is 158/98, HR 96
bpm, respiratory rate 15 /min, and oxygen saturation is 98% on room
air. Physical examination findings are significant for pulsus parvus and
tardus on neck exam, laterally displaced PMI, normal S1 but diminished
S2, 3/6 midsystolic murmur, loudest at the base and radiating to the
neck. S4 is also audible. Lungs are clear to auscultation, abdominal
examination is soft, nontender, and non-distended. There is no lower
extremity edema.
1. The mechanism for syncope in this case is most likely:
A. impaired cardiac output from fixed stenotic valve orifice
B. impaired cardiac output due to atrial tachyarrhythmia
C. impaired cardiac output due to low forward flow of blood from valve
regurgitation
D. impaired cardiac output due to low preload

Case #2
A 65 year old woman presents to the emergency room after calling 911
with a 30 minute history of chest pain. She has never had chest pain
before, but developed symptoms this morning right after eating
breakfast. She describes the pain as tightness in her epigastrium
and also moving up to the middle of her chest. She reports associated
nausea and diaphoresis but no vomiting. Her pain is 8/10 in severity.
She feels mildly short of breath, but that was improved in the
Emergency room when she received oxygen. She denies any recent
1

lower extremity edema, PND, or orthopnea. She has noticed mildly

increased dyspnea on exertion over the past several weeks but no
prior chest pain. She has a medical history significant for diabetes
mellitus and hypertension. She does not have any family history of
cardiac problems, and she does not smoke cigarettes.
Physical Exam:
T = 37.9 C, HR = 105, BP 150/85, RR 20, O2 sat 97% room air
Skin: no rashes, warm
Neck: JVP 9 cm
Chest: Clear to auscultation bilaterally, no crackles.
CV: mildly tachycardic S1, S2, +S4. No murmurs or rubs. Non-displaced
PMI/
Abdomen: soft, nontender, nondistended, no hepatosplenomegaly
Extremities: no lower extremity edema
Cardiac enzymes drawn in the emergency room show normal CK-MB
and troponin. An EKG was performed on the patient: (see below)

1. Based on the above information, the best treatment plan for this
patient is:
A. intravenous fluids
B. aspirin, nitrate, and beta blocker
C. aspirin, nitrate, beta blocker, and unfractionated heparin
D. aspirin, nitrate, beta blocker, unfractionated heparin, and primary
percutaneous coronary intervention

The patient receives treatment and is observed overnight in the

hospital. The following morning, she develops acute onset of shortness
of breath. Her vital signs are now as follows:
HR = 110, BP 155/85, RR 24, O2 saturation 86% RA
Exam:
General: moderate distress
Neck: jugular venous distension 13 cm
Lungs: rales at both lung bases 1/2 way up
CV: tachycardic S1, S2, blowing holosystolic murmur loudest at apex,
with radiation to axilla
Extremities: +1 edema in lower extremities
2.The patients sudden decompensation is most likely due to:
A. sudden decrease in left ventricular systolic function
B. sudden increase in left atrial pressure
C. sudden increase in afterload
D. sudden decrease in preload
Case #3
cc: shortness of breath
history: Mr. Coeur is a 65 year old male who presents to the Emergency
room with a 6 month history of progressive shortness of breath. He has
not been to a doctor in over 10 years and has generally been in good
health until the recent onset of symptoms. He was told that he had
high blood pressure in the past, but has never been on medications for
it or for any other medical problems. Over the past six months, he has
developed worsening shortness of breath. Initially, he noticed it when
walking up the subway stairs or running to catch a bus. Over the past
one month, his symptoms have worsened to occur when walking one
block. He denies any chest pain. Over the past month, he has also had
increasing difficulty sleeping at night. He wakes up short of breath and
has noticed that he sleeps better with three pillows propped under his
head. He has also noticed increasing swelling in his legs over the past
few weeks. On the day of admission, he went to out to eat with a friend
and had pizza for lunch. Later that evening, he developed significantly
worse shortness of breath, which occurred when he was sitting down
and not exerting himself. He called 911 and was brought to the
Emergency room. He denies current chest pain, palpitations, or
dizziness.
physical exam:

T = 37.0 degrees C, HR 110, BP 165/95, RR 20, O2 sat. 91% on room

air, Height 510, weight 205 lb.
Skin: no rashes, warm
Neck: jugular venous pressure 11 cm
Heart: PMI laterally displaced, normal S1, S2. Grade 2/6 holosystolic
murmur at the apex. +S3 present.
Lungs: crackles at both bases way up lung fields
Abdomen: soft, nondistended. Mild hepatomegaly appreciated.
Extremities: 2+ edema to the knees
An EKG is done showing sinus tachycardia with rate 110 bpm, normal
axis, normal intervals, left atrial and right atrial enlargement, LVH, and
no acute ST changes.
Question #1
Which of the following treatments is most appropriate to administer to
the patient at this time?
A. intravenous fluids
B. loop diuretic
C. beta blocker
D. dobutamine
Case #4
A 32 year old man goes to his primary care doctor with new complaints
of chest pain starting three months ago. The pain occurs when he
exerts himself, particularly when he exercises at the gym. He describes
it as a substernal tightness that is relieved with rest. He also reports
mild increase in shortness of breath with exercise, but no leg swelling,
PND, or orthopnea. His past medical history is significant for GERD and
he is on omeprazole. He denies any significant family history for
cardiovascular disease. He also denies any tobacco, drug, or alcohol
use. On physical examination, his temperature is 37 degrees Celsius,
blood pressure is 155/50, HR 96 bpm, respiratory rate 15/min, and
oxygen saturation is 98% on room air. Physical examination findings
are significant for hyperdynamic pulsus. His heart exam shows an
apical impulse that is displaced to the left and downward. There is a
normal S1 and S2, 3/6 blowing diastolic murmur loudest at the left
sternal border. Lungs are clear to auscultation, abdominal examination
is soft, nontender, and non-distended. There is no lower extremity
edema.

An EKG taken in the doctors office shows normal rate and rhythm with
no ST segment changes.
1. The mechanism for chest pain in this case is most likely:
A. increased myocardial oxygen demand due to a hypertrophied left
ventricle
B. increased myocardial oxygen demand due to chronically elevated
heart rate
C. decreased myocardial oxygen supply due to fixed, obstructive
atherosclerotic plaques in his coronary arteries
D. decreased myocardial oxygen supply due to decreased coronary
perfusion pressure