ENARM

Curso Dr. Huitrón

TALLER DE TRADUCCIÓN DE
CASOS CLÍNICOS
Dr. Manuel Correa Verduzco
docverduzco@Gmail.com
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Curso Dr. Huitrón

A 65-year-old patient diagnosed with heart failure class NYHA III complained
of a worsening of his dyspnea. He has a history of acute pulmonary edema.
He takes ACEI, furosemide, spironolactone and aspirin. Physical exploration
with bilateral pulmonary crackles.

Paciente de 65 años con diagnóstico de insuficiencia cardiaca NYHA III acude

por empeoramiento de su disnea. Tiene antecedente de edema agudo
pulmonar. Toma IECA, furosemide, espironolactona y aspirina. Exploración
física con crepitantes pulmonares bilaterales.
 ENARM
Curso Dr. Huitrón
Of the following, better therapeutic
management for increasing survival rate
a) Calcium antagonists and oral nitrates
b) Replace aspirin with clopidogrel
c) Bronchoaspiration and culture
d) Start treatment with beta blockers
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Curso Dr. Huitrón
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Curso Dr. Huitrón

69-year-old patient diagnosed with heart failure treated with ACEI, beta-
blocker, diuretic and aldosterone blocker. Goes to the ER for dizziness, BP
85/40 ECG shows left bundle branch block with 70 bpm. Other studies
without abnormalities.

Paciente de 69 años diagnosticado con insuficiencia cardiaca tratado con

IECA, beta bloqueador, diurético y bloqueador de aldosterona. Acude a
urgencia por mareo, TA 85/40 ECG muestra bloqueo de rama izquierda con
70 lpm. Resto de estudios sin anormalidades.
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Curso Dr. Huitrón
One of the drugs taken is the probable cause,
what would you recommend
a) Decrease beta blocker dose
b) Decrease diuretic dose
c) Decrease ACEI dose
d) Decrease aldosterone blocker dose
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Curso Dr. Huitrón
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Curso Dr. Huitrón

A 70-year-old woman with a history of diabetes and heart attack 1 year ago.
LVEF 30% in treatment with aspirin, furosemide, enalapril. Goes to
consultation for dyspnea of small efforts. BP 140/70 HR 70

Mujer de 70 años con antecedente de diabetes e infarto hace 1 año. FEVI

30% en tratamiento con aspirina, furosemida, enalapril. Acude a consulta
por disnea de pequeños esfuerzos. TA 140/70 FC 70
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Curso Dr. Huitrón
Which of the following options Will be more
important towards prognosis
a) Change enalapril by captopril
b) Start digoxine
c) Start spironolactone
d) Start metoprolol
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Curso Dr. Huitrón
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Curso Dr. Huitrón
35-year-old patient consulted for progressive dyspnea of several months of
evolution. Until reaching minimal efforts. No personal or family history of
interest. BP 110/70 HR 80 systolic murmur III / VI displacement of cardiac
apex to 7th intercostal space. Palpation of the right hypochondrium is painful.
ECG shown:

Paciente de 35 años consulta por disnea progresiva de varios meses de

evolución. Hasta llegar a mínimos esfuerzos. Sin antecedentes personales o
familiares de interés. TA 110/70 FC 80 soplo sistólico III/VI desplazamiento
de ápex cardiaco a 7º espacio intercostal. Palpación de hipocondrio derecho
es dolorosa. Se muestra ECG:
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Curso Dr. Huitrón
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Curso Dr. Huitrón

Diagnostic impression of this ECG

a) Right Branch blockage
b) Atrial fibrilation with normal ventricular response
c) Lower infarction
d) Left Branch blockage
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Curso Dr. Huitrón
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Curso Dr. Huitrón

Best diagnostic maneuver at this moment

a) Transthoracic echocardiogram
b) Transesophageal echocardiogram
c) MRI
d) CT scan
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Curso Dr. Huitrón

Better maneuver at this moment

 ENARM
Curso Dr. Huitrón
An 80-year-old female, arriving at the emergency room at 4 am complaining
of sudden dyspnea at rest, and dry cough, opressive thoracic pain. History of
essential high blood pressure and myocardial infarction leading to
progressive dyspnea. BP 220/130 HR 100 RR 30 O2 sat 70% auscultation
shows pulmonary rales and expiratory wheezings in both hemithorax.

Paciente femenina de 80 años acude a urgencias a las 4 am quejándose de

disnea súbita en reposo, tos seca, dolor torácico opresivo. Antecedente de
hipertensión esencial e IAM llevando a disnea progresiva. TA 220/130 FC 100
FR 30 SATO2 70% la auscultación revela crepitaciones y sibilancia espiratoria
en ambos hemitórax.
 ENARM
Curso Dr. Huitrón

Immediate management for this case

a) Administer morphine reducing preload and improve anxiety and dyspnea
b) Intravenous nitroglycerine for coronary vasodilator effect
c) Nitroprusside as vasodilator
d) Furosemide for reducing preload and improve pulmonary edema
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Curso Dr. Huitrón
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Curso Dr. Huitrón

A 53-year-old woman presented with ankle edema and dyspnea. She has a
history of nocturnal paroxysmal dyspnea. Physical examination with
hepatomegaly, jugular venous distention, lower limb edema. Chest x-ray
shows cardiomegaly.

Mujer de 53 años acude por edema en tobillos, y disnea. Cuenta con

antecedente de disnea paroxística nocturna. Exploración física con
hepatomegalia, distensión venosa yugular, edema de miembros inferiores.
Radiografía de tórax muestra cardiomegalia.
 ENARM
Curso Dr. Huitrón

Initial maneuver of greater utility for this patient

a) ACEI and diuretic
b) Beta blocker
c) Spironolactone
d) Calcium antagonist
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Curso Dr. Huitrón

Following maneuver for this patient

a) Electrocardiogram
b) Echocardiogram
c) Doppler of lower limbs
d) Referr to second level center
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Curso Dr. Huitrón
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Curso Dr. Huitrón

A 25-year-old female patient presented with dyspnea of ​2 years of evolution

that has been progressive. Currently also presenting ortopnea. Dyspnea is
presented with the distance from the bedroom to the kitchen. As an
antecedent of importance, she refers recurrent respiratory infections in
childhood.
Paciente femenina de 25 años acude por disnea de 2 años de evolución que
ha sido progresiva. Actualmente presentando también ortopnea y la disnea
se presenta con la distancia de su cuarto a la cocina. Como antecedente de
importancia refiere infecciones de vías respiratorias de repetición en la
infancia.
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Curso Dr. Huitrón
According to the NYHA what functional class
corresponds to your patient?
a) ICC I
b) ICC II
c) ICC III
d) ICC IV
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Curso Dr. Huitrón
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Curso Dr. Huitrón

HEART FAILURE
• LV failure: either due to systolic or diastolic dysfunction. Predominant
symptoms are those of low cardiac output and congestion, including
dyspnea.
• RV failure: symptoms of fluid overload predominate: usually right
ventricule failure is secondary to left ventricle failure.
• Assessment of LV function is a crucial part of diagnosis and management
• Treatment with ACE inhibitors, aldosterone antagonists and beta blockers
increase survival rate.
 ENARM
Curso Dr. Huitrón

Acute heart failure and pulmonary edema

• Acute onset or worsening of dyspnea at rest
• Tachycardia, diaphoresis, cyanosis
• Pulmonary rales, rhonchi, expiratory wheezing
• Radiograph shows interstitial and alveolar edema with or without
cardiomegaly
• Arterial hypoxemia
 ENARM
Curso Dr. Huitrón

A 55-year-old chronic hypertensive patient attended the clinic due to

headache, decreased visual acuity. BP 209/140, presents papilledema, flame-
hemorrhage, bibasal rales in lungs.

Paciente de 55 años hipertenso crónico acude a consulta por presentar

cefalea, disminución de agudeza visual. TA 249/140, presenta papiledema,
hemorragia en llama, estertores bibasales en pulmones.
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Curso Dr. Huitrón
What would be the first goal of management for
this patient?
a) 20-25% decrease in sistolic BP in 1 hour
b) 20-25% decrease in mean BP in 1 hour
c) 20-30% decrease in mean BP in 30 minutes
d) 20-25% decrease in mean BP in 30 minutes
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Curso Dr. Huitrón
What would be the first goal of management for
this patient?
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Curso Dr. Huitrón

Of the following, choose the best suited drug

a) Nitroglycerine
b) Nitroprusside
c) Esmolol
d) Fentolamine
 ENARM
Curso Dr. Huitrón
What would be the first goal of management for
this patient?
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Curso Dr. Huitrón
A man comes for consultation commenting that his blood pressure was taken
outside of a super market and was told BP was of 150/90 so they repeated
the measurement and found 160/90. They advised him to go to a doctor. The
patient comments being healthy, and feeling good.

Un hombre acude a consulta al comentar que se le tomó la presión afuera

de un super mercado y le comentaron cifras de TA de 150/90 por lo que le
repitieron la medición y encontraron 160/90. Le aconsejaron acudir con un
médico. El paciente comenta ser sano, y sentirse bien.
 ENARM
Curso Dr. Huitrón

Next step in care for this patient

a) Administer sublingual nifedipine
b) Administer a thiazide
c) Schedule dedicated office visit a month apart and lifestyle modifications
d) Start with lifestyle modifications, low sodium diet and initiate with ACEI
since these blood pressure figures are already considered chronic
hypertension
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Curso Dr. Huitrón
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Curso Dr. Huitrón

60 year-old female visits her physician for check-up over diabetes and
hypertension. She was feeling Good, so she stopped taking her medications.
BP 160/90. Analysis: creatinine 1.9, microalbuminuria, creatinine clearance
41.

Femenina de 60 años acude a consulta con su médico por chequeo de su

diabetes e hipertensión. Se ha sentido bien, por lo que dejó de tomar sus
medicamentos. TA 160/90 Laboratoriales: creatinina 1.9, microalbuminuria,
TFG 41.
 ENARM
Curso Dr. Huitrón
Most useful management in treating this
patient’s nephropathy?
a) Calcium antagonist
b) Angiotensin converter enzime inhibitors (ACEIs)
c) Beta blockers
d) Angiotensin receptor blockers (ARB’s)
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Curso Dr. Huitrón
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Curso Dr. Huitrón

A 70-year-old male patient with a history of myocardial infarction. He comes

to the emergency room due to progressive respiratory distress, pulmonary
crackles, he mentions orthopnea and examination reveals jugular
engorgement

Paciente masculino de 70 años con antecedente de infarto al miocardio e

insuficiencia cardiaca. Acude a urgencias por dificultad respiratoria
progresiva, crepitaciones pulmonares, menciona ortopnea y la exploración
revela ingurgitación yugular
 ENARM
Curso Dr. Huitrón
To help the prognosis of your patient, what
would you advise?
a) Start digoxine Will help survival rate
b) Start ACEI Will help survival rate on full dose
c) Start ACEI Will help survival rate on HF dose
d) Start dietary salt restriction Will help suvival rate
 ENARM
Curso Dr. Huitrón
An 80-year-old female, arriving at the emergency room at 4 am complaining
of sudden dyspnea at rest, and dry cough, opressive thoracic pain. History of
essential high blood pressure and myocardial infarction leading to
progressive dyspnea. BP 220/130 HR 100 RR 30 O2 sat 70% auscultation
shows pulmonary rales and expiratory wheezings in both hemithorax.

Paciente femenina de 80 años acude a urgencias a las 4 am quejándose de

disnea súbita en reposo, tos seca, dolor torácico opresivo. Antecedente de
hipertensión esencial e IAM llevando a disnea progresiva. TA 220/130 FC 100
FR 30 SATO2 70% la auscultación revela crepitaciones y sibilancia espiratoria
en ambos hemitórax.
 ENARM
Curso Dr. Huitrón

Immediate management for this case

a) Administer morphine reducing preload and improve anxiety and dyspnea
b) Intravenous nitroglycerine for coronary vasodilator effect
c) Nitroprusside as vasodilator
d) Furosemide for reducing preload
 ENARM
Curso Dr. Huitrón
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Curso Dr. Huitrón
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Curso Dr. Huitrón

A 70-year-old woman went to the emergency room due to chest pain that
lasted 2 hours. ECG shows ST elevation of 2 mV in V4, V5 and V6.

Mujer de 70 años acude a urgencias por dolor torácico de 2 horas de

evolución. ECG muestra supradesnivel del ST de 2 mV en V4, V5 y V6.
 ENARM
Curso Dr. Huitrón

Best suited therapeutic option

a) Aspirine
b) Clopidogrel
c) Enoxaparin
d) Heparin
 ENARM
Curso Dr. Huitrón

Best suited therapeutic option

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Curso Dr. Huitrón

Cardiac catheterization was performed after discovering an 85% coronary

obstruction. The patient's son read on the internet that there is a risk of
restenosis after the procedure.

Se le realiza posteriormente cateterismo cardiaco por una obstrucción

coronaria del 85% el hijo de la paciente leyó en internet que existe un riesgo
de reestenosis después del procedimiento
 ENARM
Curso Dr. Huitrón
Which therapeutic measure best prevents this
complication
a) Stent implantation
b) Daily administration of aspirin
c) Daily administration of pravastatin
d) Administration of oral antigoaculants for 12 months
 ENARM
Curso Dr. Huitrón
Which therapeutic measure best prevents this
complication
a) Stent implantation
b) Daily administration of aspirin
c) Daily administration of pravastatin
d) Administration of oral antigoaculants for 6 months
 ENARM
Curso Dr. Huitrón

60-year-old male complains of precordial pain after medium-level efforts.

On echocardiogram depressed left ventricle function of 22% is revealed
along with significant stenosis of 3 different vessels.

Masculino de 60 años se queja de dolor precordial después de medianos

esfuerzos. En el ecocardiograma se encuentra función ventricular izquierda
disminuída de 22% junto con estenosis de 3 vasos diferentes.
 ENARM
Curso Dr. Huitrón

Which treatment is best suited in this case?

a) Percutaneous revascularization
b) Medical treatment
c) Myocardial revascularization surgery
d) Cardiac transplant
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Curso Dr. Huitrón
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Curso Dr. Huitrón
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Curso Dr. Huitrón

Male patient of 66 years of age, hypertensive and smoker, with known right
branch block, with LDL cholesterol values of 175 mg / dl, who is in treatment
with enalapril. Recently, an echocardiography was performed, detecting
ventricular hypertrophy and systolic ventricular dysfunction was described
with an ejection fraction of 34%. He refers sensation of chest tightness
triggered by effort of about 6 months of evolution. Treatment with aspirin is
started and an ergometry is requested.
 ENARM
Curso Dr. Huitrón

Paciente varón de 66 años, hipertenso y fumador, con bloqueo de rama

derecha conocido, con cifras de colesterol LDL de 175 mg/dl, que está en
tratamiento con enalapril. Recientemente se realizó una ecocardiografía,
detectando hipertrofia ventricular en la que se describe disfunción
ventricular sistólica con una fracción de eyección del 34%. Refiere un cuadro
de opresión torácica de esfuerzo de unos 6 meses de evolución. Se inicia
tratamiento con aspirina y se solicita la realización de una ergometría.
 ENARM
Curso Dr. Huitrón

During the realization of the ergometry he presented the anginal symptoms

and the patient suddenly falls to the ground unconscious, registering the
following ECG

Durante la realización de la ergometría, presentó sus síntomas anginosos, y el

paciente cayó al suelo súbitamente, inconsciente, se registra el siguiente ECG
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Curso Dr. Huitrón
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Curso Dr. Huitrón

Electrocardiographic diagnosis for this patient

a) Torsade des pointes

b) Ventricular flutter
c) Ventricular tachycardia
d) Supraventricular tachycardia
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Curso Dr. Huitrón
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Curso Dr. Huitrón
Best suited management for your patient at this
moment
a) Intravenous atropine
b) Place pacemaker
c) Immediate defibrillation
d) Intravenous amiodarone
 ENARM
Curso Dr. Huitrón
Acute coronary syndrome without ST segment
elevation
• Distinction with and without ST-segment elevation is essential for
reperfusion therapy
• Fibrinolytic therapy is harmful in acute syndrome without ST segment
elevation
• Antiplatelet and anticoagulation therapies and coronary intervention are
mainstays of treatment
 ENARM
Curso Dr. Huitrón
A 59-year-old man with no history of ischemic heart disease, known diabetic
and smoker of 20 cigarettes a day. Go to an emergency service for having
started about 30 minutes earlier, while walking, to have oppressive
retrosternal pain and sweating. BP is 150/100 and the rest of the scan is
normal. The levels of CPK are normal and the ECG shows no significant
alteration.
Hombre de 59 años sin antecedentes de cardiopatía isquémica, conocido
diabético y fumador de 20 cig/día. Acude a un servicio de emergencias por
iniciar 30 minutos previos, mientras caminaba, con dolor opresivo
retroesternal y sudoración. TA 150/100 resto de exploración normal. Niveles
de CPK son normales y el ECG no muestra alteraciones significativas
 ENARM
Curso Dr. Huitrón
What attitude, of the following, would you
advise?
a) Request a lung-scan
b) Observation with ECG and serial cardiac enzymes for 6-12 hours
c) Home observation, rest and analgesia
d) Start fibrinolytics treatment
 ENARM
Curso Dr. Huitrón

Patient of 73 years, with no personal history of interest, go to an emergency

department for suffering intense chest pain with irradiation to neck of 4
hours of duration. On the electrocardiogram the ST segment elevation in DI,
V5 and V6. There is no medical contraindication for the anticoagulation

Paciente de 73 años, sin antecedentes personales de interés, acude a

urgencias por presentar intenso dolor de pecho con irradiación al cuello de 4
horas de duración. El electrocardiograma con elevación del segmento ST en
DI, V5 y V6. No existe contraindicación para la anticoagulación
 ENARM
Curso Dr. Huitrón

Optimal strategy to treat this patient

a) Thrombolytic therapy with intracoronary tissue plasminogen activator
b) Thrombolytic therapy with intracoronary tissue plasminogen activator
plus aspirin
c) Thrombolytic therapy with intracoronary tissue plasminogen activator
plus heparin
d) Thrombolytic therapy with intracoronary tissue plasminogen activator
plus heparin and aspirin
 ENARM
Curso Dr. Huitrón

It is a 78-year-old patient, admitted to the Coronary Unit, on the third day of

evolution of an acute inferior myocardial infarction and thrombolytic therapy.
Suddenly, the patient loses consciousness and presents severe hypotension
and lack of pulse, with persistence of QRS complexes in the monitor. Cyanosis
and jugular engorgement appear on the physical examination.

Es un paciente de 78 años, admitido en la unidad coronaria, cursando su

tercer día de evolución de un infarto de cara inferior, y trombolisis.
Repentinamente, pierde el conocimiento y presenta hipotensión severa, así
como falta de pulso. Persistencia de complejos QRS en el monitor. Cianosis e
ingurgitación yugular se observan al examen físico
 ENARM
Curso Dr. Huitrón
What would be your diagnostic suspicion
a) Acute hypovolemic shock
b) Papillary muscle rupture
c) Intraventricular septum rupture
d) Free wall rupture and tamponade
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Curso Dr. Huitrón
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Curso Dr. Huitrón

A previously healthy 58-year-old man admitted with serious retrosternal pain,

at rest, of four hours evolution, irradiated to his jaw. The ECG shows marked
elevation of ST in DII, DIII, and aVF. Troponin is positive. After a few hours,
marked oliguria and hypotension appear (BP 90/60 mmHg).
Hombre de 58 años, previamente sano, ingresa con dolor retroesternal
grave, en reposo, de 4 horas de evolución, con irradiación a la mandíbula.
ECG muestra elevación de ST en DII, DIII y aVF. La troponina está positiva.
Unas horas después, inicia con oliguria e hipotensión (TA 90/60)
 ENARM
Curso Dr. Huitrón
Which of the following treatments is the
most suitable for immediate care?
a) IV fluids
b) Digoxine
c) Noradrenaline
d) Dopamine
 ENARM
Curso Dr. Huitrón

A 56-year-old patient admitted to the hospital for acute myocardial infarction

of inferior face. At four o'clock he is bradycardic (Sinus rhythm at 38 bpm) and
hypotensive (80/50 mmHg), without new changes in the ECG nor enzymatic.

Paciente de 56 años ingresado al hospital por infarto agudo al miocardio de la

cara inferior. A las 4 en punto se pone bradicárdico (ritmo sinusal de 38 lpm) e
hipotenso (89/50 mmHg) sin nuevos cambios en el ECG ni tampoco
enzimáticos
 ENARM
Curso Dr. Huitrón
Which of the following, is the most
appropriate therapeutic measure?
a) IV fluid administration
b) External pacemaker
c) IV atropine
d) IV dobutamine
 ENARM
Curso Dr. Huitrón

A 71-year-old woman admitted with a diagnosis of acute anterolateral

myocardial infarction. On the 4th day of hospitalization, after a favorable
evolution, she suddenly develops hypotension, tachycardia and tachypnea
with new elevation of pressure in the jugular vein, bilateral diffuse wet rales
and thrills palpable on left lower parasternal edge with holosystolic murmur
IV / VI, irradiated at left lower parasternal edge. Paradoxical pulse is not
objectified. ECG without changes respect to the initial registration. The CPK
follows the descending evolution regarding the value of income.
 ENARM
Curso Dr. Huitrón

Mujer de 71 años admitida con diagnóstico de infarto anterolateral. En el 4to

día de hospitalización, después de una evolución favorable, desarrolla
súbitamente hipotensión, taquicardia, taquipnea y elevación de la presión
venosa yugular, crepitantes bilateres y thrill palpable en el borde paraesternal
izquierdo, murmullo holosistólico IV/VI, con irradiación a borde paraesternal
izquierdo. No se observa pulso paradójico. ECG sin cambios respecto al inicial.
CPK continúa disminuyendo.
 ENARM
Curso Dr. Huitrón

Your diagnosis will be:

a) Paroxysmal ventricular tachycardia
b) Massive pulmonary thromboembolism
c) Ventricular septal rupture
d) Left ventricle blockage
 ENARM
Curso Dr. Huitrón

She then presents the following ECG

 ENARM
Curso Dr. Huitrón

Electrocardiographic diagnosis

a) Atrial fibrilation
b) Ventricular fibrilation
c) Ventricular tachycardia
d) Tamponade
 ENARM
Curso Dr. Huitrón

What is the clinical relevance of her arrythmia

a) It leads to chronic heart failure

b) It relates to Good prognosis when diagnosed in early stage
c) It relates to bad prognosis
d) It has no clinical relevance
 ENARM
Curso Dr. Huitrón

What is the clinical relevance of her arrythmia

 ENARM
Curso Dr. Huitrón
Acute myocardial infarction with ST-segment
elevation
• Sudden development of more than 30 minutes anterior chest discomfort,
felt as “gas” or pressure
• Sometimes painless, masquerading as syncope, stroke, shock, heart failure
• ECG: ST-segment elevation or left bundle Branch block
• Immediate reperfusion treatment is warranted
• Primary PCI within 90 minutes is superior to fibrinolytic therapy
• Fibrinolytic therapy reduces mortality if given within 12 hours of onset
symptoms
 ENARM
Curso Dr. Huitrón

A 79-year-old patient with a background of heart attack 5 years ago is

brought to the clinic over mood swings, keeping awake at night and is
disoriented.

Paciente de 79 años con antecedente de infarto hace 5 años es llevado a

consulta por cambios de humor, permanecer despierto en la noche y estar
desorientado.
 ENARM
Curso Dr. Huitrón
What would be the most suitable management
for treating this patient’s delirium?
a) Olanzapine
b) Haloperidol
c) Risperidone
d) Sertraline
 ENARM
Curso Dr. Huitrón

Acute inflammatory pericarditis

 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

• Precordial chest pain, usually precipitated by stress or exertion, revlieved
rapidly by rest or nitrates
• ECG evidence of ischemia during pain or stress testing
• Angiographic demonstration of significant obstruction of major coronary
vessels or coronary spasm responds to intracoronary nitroglycerin or
calcium channel blockers
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

• Precordial chest pain, usually precipitated by stress or exertion, revlieved
rapidly by rest or nitrates
• ECG evidence of ischemia during pain or stress testing
• Angiographic demonstration of significant obstruction of major coronary
vessels or coronary spasm responds to intracoronary nitroglycerin or
calcium channel blockers
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

• Precordial chest pain, usually precipitated by stress or exertion, revlieved
rapidly by rest or nitrates
• ECG evidence of ischemia during pain or stress testing
• Angiographic demonstration of significant obstruction of major coronary
vessels or coronary spasm responds to intracoronary nitroglycerin or
calcium channel blockers
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

60-year-old patient consults over a weighted sensation on his chest,

presented following exertion, irradiating to his jaw. He has no previous
history of heart disease. He is known with diagnosis of diabetes and
essential hypertension.

Paciente de 60 años acude a consulta por una sensación de pesadez en su

pecho, que se sigue del esfuerzo, con irradiación a su mandíbula. No tiene
antecedentes de enfermedades cardíacas. Se conoce diabético e hipertenso.
 ENARM
Curso Dr. Huitrón
First maneuver that should be done to this
patient
a) Electrochardiogram
b) Echocardiogram
c) Stress test
d) Referr to second level center
 ENARM
Curso Dr. Huitrón
If your previous test is positve, what should be
done next
a) Start nitrates
b) Stress test
c) Echocardiogram
d) Referr to second level center
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

• Precordial chest pain, usually precipitated by stress or exertion, revlieved
rapidly by rest or nitrates
• ECG evidence of ischemia during pain or stress testing
• Angiographic demonstration of significant obstruction of major coronary
vessels or coronary spasm responds to intracoronary nitroglycerin or
calcium channel blockers
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

• Precordial chest pain, usually precipitated by stress or exertion, revlieved
rapidly by rest or nitrates
• ECG evidence of ischemia during pain or stress testing
• Angiographic demonstration of significant obstruction of major coronary
vessels or coronary spasm responds to intracoronary nitroglycerin or
calcium channel blockers
 ENARM
Curso Dr. Huitrón
Best test to stablish prognosis over this group of
patients
a) Stress test
b) Echocardiogram
c) Coronary angiography
d) Electrocardiogram
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

 ENARM
Curso Dr. Huitrón
For this particular patient, calculate the
estimated maximum heart rate
a) 134 bpm
b) 136 bpm (220-edad) x 0.85
c) 138 bpm
d) 140 bpm
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

 ENARM
Curso Dr. Huitrón

Gold standard for ischemic coronary lesions

a) Coronary angiography
b) Doppler USG
c) Echocardiogram
d) Stress test
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

 ENARM
Curso Dr. Huitrón

70-year-old patient comes to the clinic after presenting multiple thoracic

pains following exertion and the last time after a copious meal. He’s known
with diagnosis of diabetes, hypertension and dyslipidemia for over 20 years.
He is overwieght

Paciente de 70 años acude a consulta por presentar múltiples dolores

torácicos posteriores al ejercicio y la última vez posterior a una comida
copiosa. Se conoce diabético, hipertenso y dislipidémico desde hace 20
años. Tiene sobrepeso
 ENARM
Curso Dr. Huitrón
Of all his risk factors, which one is of most
importance
a) Dyslipidemia
b) Diabetes
c) Age
d) Obesity
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

 ENARM
Curso Dr. Huitrón
What is the action mecanism for the first line
drug?
a) Inhibits hydroximethylglutaryl coenzyme A reductase
b) Inhibits intestinal absortion of cholesterol
c) Increases HDL levels
d) Inhibits hydroximethylglutaryl conezime B reductase
 ENARM
Curso Dr. Huitrón

Chronic stable angina pectoris

 ENARM
Curso Dr. Huitrón

Acute inflammatory pericarditis

• Anterior pleuritic chest pain that is worse supine than upright
• Pericardial rub
• Fever is common
Rub=frote
• Erythrocyte sedimentation rate and inflammatory CRP usually elevated
• ECG reveals diffuse ST-segment elevation and PR depression
 ENARM
Curso Dr. Huitrón

A 75-year-old woman admitted to the emergency room due to syncope. BP

80/40 HR 115 O2-sat 91% Jugular engorgement is observed. ECG shows sinus
tachycardia with electrical alternation.

Mujer de 75 años que ingresa a urgencias por síncope. TA 80/40 FC 115

SATO2 91% Se observa ingurgitación yugular. ECG muestra taquicardia
sinusal con alternancia eléctrica.
 ENARM
Curso Dr. Huitrón
Which of the following tests would you advise
next?
a) Ventilation/perfusion scan
b) Thoraic CT-scan
c) Hemogram
d) Echocardiography
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
The echocardiogram showed 15 mm thickness
pericardial effusion, this means:
a) Mild pericardial effusion
b) Moderate pericardial effusion
c) Severe pericardial effusion
d) Chronic pericarditis
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

A 32-year-old patient presents after 8 days of evolution with fever and chest
pain that increases with respiratory movements, presenting cardiac rub on
auscultation
Paciente de 32 años presenta 8 días de evolución con fiebre y dolor torácico
que aumenta con movimientos respiratorios, se ausculta frote.
 ENARM
Curso Dr. Huitrón

Pressumptive diagnosis at this moment

a) Acute pericarditis
b) Tuberculous pericarditis
c) Chronic pericarditis
d) Cardiac tamponade
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Most suitable treatment for this patient

a) Ibuprofene
b) Aspirine
c) Colchicine
d) Ibuprofene + colchicine
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
On the echocardiogram, clinical finding of attrial
collapse means
a) Constrictive pericarditis
b) Acute pericarditis
c) Chronic pericarditis
d) Cardiac tamponade
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Advised treatment for your diagnosis

a) Pericardiocentesis
b) Observation
c) High dose diuretic
d) Low doce diuretic
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

A 75-year-old patient with a history of AMI 3 weeks ago came to the clinic due
to chest pain, low fever. Pericardial rub on auscultation

Paciente de 75 años con antecedente de IAM hace 3 semanas acude a

consulta por presentar dolor torácico, fiebre baja. Se ausculta frote
pericárdico
 ENARM
Curso Dr. Huitrón

What diagnosis would you suspect

a) Dressler syndrome
b) Acute pericarditis
c) Chronic pericarditis
d) Another heart attack
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Pericardial effusion and tamponade

• Pericardial effusion
- Clinical impact determined by the speed of accumulation
- May or may not cause pain
• Tamponade
- Tachycardia with elevated JVP and hypotension or paradoxical pulse
- Low voltage or electrical alternans
- Echocardiography is diagnostic
 ENARM
Curso Dr. Huitrón

Restrictive cardiomyopathy
• Right heart failure tends to dominate over left heart failure
• Pulmonary hypertension is present
• Echocardiography is key to diagnosis
• Myocardial biopsy or cardic MRI to confirm amyloid
 ENARM
Curso Dr. Huitrón

Hypertrophic cardiomiopathy
• May present with dyspnea, chest pain, syncope
• Though LV outflow gradient is classic, symptoms primarily relate to
diastolic dysfunction
Outflow=salida, eyección potente
• Echocardiogram is diagnostic
• Any área of LV wall thickness greater tan 1.5 cm defines the disease
• Increased risk of sudden death
Thickness=grosor
Sudden=súbito Thick=grueso
 ENARM
Curso Dr. Huitrón

Dilated cardiomyopathy
• Symptoms and signs of heart failure
• Echocardiogram confirms LV dilation, thinning, global dysfunction
• Severity of RV dysfunction critical in long-term prognosis
Heart Failure=Insuficiencia cardiaca
HF=ICC Thinning=adelgazamiento
Thin=delgado
 ENARM
Curso Dr. Huitrón
A 47-year-old patient consulted for edema of the lower limbs that had been
evolving over the last 6 months, currently presenting pain in the right
hypochondrium. He believes to have had this disease previously a some years
ago, he had purple edematized eyelid, myalgia and fever and being
constipated since. He says he cannot sleep lying down. He has bilateral
pulmonary rales.
Paciente de 47 años consulta por edema de miembros inferiores de 5 días
de evolución, presentando actualmente dolor en hipocondrio derecho. Cree
haber estado enfermo de lo mismo hace años, con edema palpebral
violáceo, mialgia y fiebre, y estreñimiento desde entonces. Menciona no
poder dormir acostado. Tiene crépitos pulmonares bilaterales.
 ENARM
Curso Dr. Huitrón

Most likely diagnosis that explains his symptoms

a) Subacute heart attack

b) Acute pericarditis
c) Hypertrophic cardiomiopathy
d) Dilated cardiomiopathy
 ENARM
Curso Dr. Huitrón
The probable ethiology explaining this patient’s
myocardiopathy is
a) Parasitic, chronic cardiomyopathy
b) Bacterial, acute cardiomyopathy
c) Viral, acute cardiomyopathy
d) Parasitic, acute cardiomyopathy
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

30-year-old smoker of a pack a day. He was diagnosed with a heart murmur

10 years ago. He presents to consultation for chest pain. ECG atrial fibrillation
of rapid ventricular response.

Paciente de 30 años, fumador de un paquete al día. Fue diagnosticado con

un soplo cardíaco a los 20 años. Se presenta a consulta por dolor torácico.
ECG fibrilación auricular de respuesta ventricular rápida.
 ENARM
Curso Dr. Huitrón

Most likely diagnosis

a) Aortic stenosis
b) Heart attack
c) Dilated cardiomyopathy
d) Hypertrophic cardiomyopathy
 ENARM
Curso Dr. Huitrón

25-year-old profesional athlete undergoes some tests after his brother

passed away of sudden death syndrome. Echocardiogram shows
hypertrophic cardiomyopathy

Paciente de 25 años, atleta profesional, se somete a algunos exámenes

después de que su hermano falleció de síndrome de muerte súbita.
Ecocardiograma muestra cardiomiopatía hipertrófica
 ENARM
Curso Dr. Huitrón
Pharmacological group best suited for this
patient
a) Beta blockers
b) Diuretics
c) ACEI
d) ARB
 ENARM
Curso Dr. Huitrón

Mitral regurgitation = insuficiencia mitral

• Hyperdinamic or prominent apical impulse
• Systolic thrill
• Atrial fibrilation common
• Midsystolic clicks , pansystolic
• Transmitted to left axilla / armpit
• Enlarged left heart
• ECG: left axis deviation, broad P waves
 ENARM
Curso Dr. Huitrón

Mitral regurgitation = insuficiencia mitral

• May be asymptomatic for years
• Severe case may cause left heart failure
• Surgery is indicated for symptoms or when left ventricle ejection fraction is
less than 60% or
• Echocardiographic left ventricle end-systolic dimensión is greater than 4cm
• Patients with functional mitral regurgitation may improve with surgical
intervention
 ENARM
Curso Dr. Huitrón

Mitral stenosis = estenosis mitral

• Fatigue, exertional dyspena, orthopnea when severe
• Symptoms may precipitate by onset of atrial fibrillation or pregnancy
• Most symptomatic patients have a mitral valve área of less than 1.5 cm2
 ENARM
Curso Dr. Huitrón

Mitral stenosis = estenosis mitral

• Malar flush
• Opening snap following S2, the closer the snap to S2 is
• Graham Steell murmur
• May lead to severe pulmonary hypertension
• ECG: broad P waves
 ENARM
Curso Dr. Huitrón

A patient reports dyspnea of ​medium effort and auscultation of a first strong

apex tone, opening snap and diastolic murmur with presystolic reinforcement.
ECG: mitral P waves.

Paciente refiere disnea de medianos esfuerzos y se ausculta un primer tono

fuerte en ápex, chasquido de apertura y soplo diastólico con refuerzo
presistólico. ECG: ondas P mitrales.
 ENARM
Curso Dr. Huitrón

Presumptive diagnosis for this patient

a) Double mitral injury

b) Mitral stenosis in atrial fibrillation
c) Aortic insufficiency
d) Mitral stenosis
 ENARM
Curso Dr. Huitrón

40-year-old nurse with a history of rheumatic fever. He presents with

progressive dyspnea, palpitations, auscultation in mitral focus shows first
strong tone, opening snap and mesodiastolic murmur.

Enfermero de 40 años con antecedente de fiebre reumática. Presenta disnea

progresiva, palpitaciones la auscultación en foco mitral muestra primer tono
fuerte, chasquido de apertura y soplo mesodiastólico.
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Which arrhythmia is more common in this

group of patients?
a) Supraventricular tachycardia
b) Ventricular fibrillation
c) Atrial fibrillation
d) Ventricular tachycardia
 ENARM
Curso Dr. Huitrón

Which arrhythmia is more common in this

group of patients?
 ENARM
Curso Dr. Huitrón

The senior resident wishes to practice surgery

or valvulopasty, which criteria should be used to
decide
a) Important growth of the left atrium
b) Alterations of repolarization of the left ventricle
c) Thrombi in left atrium
d) Chronic atrial fibrillation
 ENARM
Curso Dr. Huitrón

A 30-year-old woman with a history of rheumatic fever and exertional

dyspnea for 5 years. Currently, she has presented atrial fibrillation and
dyspnea of ​small efforts as well as orthopnea. Echocardiogram shows valvular
stenosis with 0.9 cm2, fused valves, absence of thrombi in the atria.

Mujer de 30 años con antecedente de fiebre reumática y disnea de esfuerzo

desde hace 5 años. Actualmente ha presentado fibrilación auricular y disnea
de pequeños esfuerzos así como ortopnea. Ecocardiograma muestra
estenosis valvular con 0.9 cm2, valvas fusionadas, ausencia de trombos en
las aurículas.
 ENARM
Curso Dr. Huitrón

Best suited maneuver out of the following

a) Add diuretics
b) Open heart surgery
c) Catheterization to assess valvular lesions
d) Percutaneous mitral valvulopasty
 ENARM
Curso Dr. Huitrón

Best suited maneuver out of the following

 ENARM
Curso Dr. Huitrón

A 72-year-old man with progressive dyspnea, fatigue and Little exertion

dyspnea of 5 years onset. Pandiastolic murmur is detected in mitral focus.
LVEF 40%

Hombre de 72 años con disnea progresiva, fatiga y disnea de pequeños esfuerzos

de 5 años de evolución. Se detecta soplo pandiastólico en foco mitral. FEVI 40%
 ENARM
Curso Dr. Huitrón
Which first line studies would you recommend
out of the following
a) ECG
b) Echocardiogram
c) ECG, Chest X-ray
d) Stress test
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
According to your patient’s symptoms, in which
stage of mitral valvulopathy is him?
a) A
b) B
c) C
d) D
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

The most probable etiology of your patient is

a) Rheumatic fever
b) Viral
c) Bacterial
d) Degenerative
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
Which of the following managements should be
avoided for your patient
a) Valvulopasty
b) Medical management
c) Heart surgery
d) Commissurotomy
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
Referring to medical management the mainstay
is
a) ACEI
b) Diuretics
c) Beta blockers and oral anticoagulants
d) Oral anticoagulants and calcium channel blockers
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

A 74-year-old woman was brought to the emergency room for sudden onset
of dyspnea and palpitations. At cardiac auscultation the first cardiac tone is
heard loudly. The carotid pulse varies in intensity, an open click is heard and a
telesistolic murmur is present in the ápex, never Heard before, accompanied
with 38.5°C temperature

Mujer de 74 años es traída urgencias por disnea y palpitaciones de inicio

súbito. A la auscultación cardiaca el primer tono cardiaco se escucha fuerte.
El pulso carotídeo varía en intensidad, se ausculta chasquido de apertura y
presenta soplo telesistólico en el ápex, nunca antes escuchado, acompañado
de fiebre de 38.5°C
 ENARM
Curso Dr. Huitrón

Pressumptive diagnosis for this case

a) Acute mitral regurgitation

b) Degenerative mitral regurgitation
c) Chronic mitral stenosis
d) Aortic stenosis
 ENARM
Curso Dr. Huitrón

Most likely etiology of this case

a) Degenerative
b) Viral
c) Bacterial
d) Ischemic
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
Imaging test best suited to assess cardiac
functionality
a) Transesophageal echocardiogram
b) Transthoracic echocardiogram
c) MRI
d) CT-scan
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Coarctation of the aorta

• Usual presentation is systemic hypertension
• Echocardiography is diagnostic peak gradient > 20 mmHg due to collaterals
around coarctation
• Associated bicuspid aortic valve 50-80% of patients
• Delayed pulse in femoral artery compared to brachial artery
• Systolic pressure is higher in upper extremities than in lower extremities
 ENARM
Curso Dr. Huitrón

Atrial septal defect and patent foramen ovale

• Often asymptomatic and discovered on routine physical examination
• With an atrial septal defect (ASD) and left to right shunt: RV lift, S2 widely
Split and fixed
• Echocardiography is diagnostic
• ASDs should be closed if there is evidence of an RV volume overload
regardless of symptoms
• A patent foramen ovale (PFO) present in 25% of the population, rarely can
lead to paradoxic emboli
 ENARM
Curso Dr. Huitrón

Tetralogy of Fallot
• Concentric right ventricular hypertrophy
• Right ventricular outflow obstruction due to infundibular stenosis
• Overriding aorta over septum
• Right sided aortic arch
• Arrhythmias are common
• Sudden death may occur if QRS is wide or RV becomes larga (Eisenmenger)
 ENARM
Curso Dr. Huitrón

DROP
Displaced aorta
Right ventricle hypertrophy
Opening in septum
Pulmonary valve stenosis
 ENARM
Curso Dr. Huitrón

Pulmonary valve stenosis

• Severe cases may present with right-sided heart failure
• P2 delayed, soft or abscent
• Pulmonary ejection click
• Echocardiography is diagnostic
• Peak pulmonic valve gradients greater than 60 mmHg should undergo
intervention
 ENARM
Curso Dr. Huitrón

An EKG is performed on an asymptomatic teenager showing sinus rhythm

and right bundle Branch block. Auscultation shows strong second heart
sound and Chest X-ray reveals an enlarged pulmonary arch.
Se realiza un ECG en un adolescente asintomático encontrando ritmo sinusal
y bloqueo de rama derecha. La auscultación revela segundo ruido intenso y
radiografía de pecho arco de la pulmonar agrandado.
 ENARM
Curso Dr. Huitrón

Which diagnosis would you suspect?

a) Tetralogy of Fallot
b) Pulmonary stenosis
c) Atrial septum disease
d) Ventricular septum disease
 ENARM
Curso Dr. Huitrón

An 8-year-old boy is taken to the emergency room by his mother due to

respiratory distress. The physical examination shows a continuous machinery
murmur and pulmonary congestion.

Niño de 8 años es llevado a urgencias por su madre por dificultad

respiratoria. La exploración física muestra un soplo continuo en maquinaria
y congestión pulmonar.
 ENARM
Curso Dr. Huitrón

Most likely diagnosis for this patient

a) Patent ductus arteriosus

b) Interatrial communication
c) Interventricular communication
d) Tetralogy of Fallot
 ENARM
Curso Dr. Huitrón

Anatomical closure expected time within

a) 3 days
b) 4 days
c) 5 days
d) 6 days
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

A three-month-old infant was taken to the Primary Care pediatrician's office,

as the mother reported that in recent days she became tired and sweated a
lot, in coincidence with breast-feeding. Pregnancy, childbirth and the neonatal
period had been normal, and there was no medical or surgical history of
interest. On physical examination, the pediatrician confirmed tachypnea with
mild subcostal retractions, oxygen saturation of 98% and a 3/6 grade
pansystolic murmur audible in multiple foci, with maximum intensity at the
level of the third to fourth left intercostal space. An electrocardiogram (ECG) is
performed
 ENARM
Curso Dr. Huitrón

Un lactante de tres meses de edad fue llevado a la consulta de su pediatra

de Atención Primaria, pues la madre refería que en los últimos días se
cansaba y sudaba mucho coincidiendo con las tomas. El embarazo, el parto y
el periodo neonatal habían sido normales, y no presentaba antecedentes
médico-quirúrgicos personales ni familiares de interés. En la exploración
física, el pediatra constató taquipnea con leve tiraje subcostal, saturación de
oxígeno del 98% y un soplo pansistólico grado 3/6 audible en múltiples
focos, con máxima intensidad a nivel del tercer a cuarto espacio intercostal
izquierdo. Se realiza un electrocardiograma (ECG)
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Diagnostic impression for this patient

a) Ventricular septal defect

b) Atrial septal defect
c) Foramen ovale
d) Tetralogy of Fallot
 ENARM
Curso Dr. Huitrón

Eisenmenger physiology referrs to

a) Pressure overload of RV but no in LV

b) Cyanosis, pulmonary hypertension and intracardiac shunt right to left
c) Cyanosis, pulmonary hypertension and intracardiac shunt left to right
d) Pressure overload of LV but no in RV
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

A 16-year-old male consulted for dyspnea of ​medium effort. Physical

examination with systolic murmur in second right intercostal space,
parasternal edge. ECG: right bundle branch block, right ventricular
hypertrophy.

Masculino de 16 años consulta por disnea de medianos esfuerzos.

Exploración física con soplo sistólico en segundo espacio intercostal
derecho, borde paraesternal. ECG: bloqueo de rama derecha, hipertrofia
ventricular derecha.
 ENARM
Curso Dr. Huitrón

Pressumptive diagnosis for your patient

a) Ventricular septal disease (VSD)

b) Atrial septal disease (ASD)
c) Tetralogy of Fallot
d) Aortic regurgitation
 ENARM
Curso Dr. Huitrón
Best study out of the following to assess initial
state
a) Transthoracic echocardiogram
b) Transesophageal echocardiogram
c) MRI
d) CT-scan
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

A 21-year-old male medical student who during medical practices was found
to have high blood pressure and is referred to the doctor. Blood pressure of
160/90 is confirmed and intense pulses in upper limbs, as well as decreased
femoral pulse.

Masculino de 21 años estudiante de medicina que durante prácticas en su

escuela se le encontró hipertensión arterial y es referido a la consulta. Se
corrobora presión arterial de 160/90 y pulsos intensos en miembros
superiores, así como pulso femoral disminuido.
 ENARM
Curso Dr. Huitrón
Radiography is taken with this particular finding,
known as
a) Roesler’s
b) Fallot’s
c) Minkawski’s
d) Lassegue’s
 ENARM
Curso Dr. Huitrón
It is common to find inverted 3 sign which
means
a) Preestenotic and poststenotic dilation
b) Preestenotic dilation only
c) Poststenotic dilation only
d) Generalized coartation
 ENARM
Curso Dr. Huitrón

Associated congenital valvulopathy

a) Mitral stenosis
b) Aortic stenosis
c) Bicuspid aortic valve
d) Aortic regurgitation
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Newborn male is observed cyanotic in the nursery room. A systolic murmur is

heard over the ventricular septum.

Recién nacido masculino se observa cianótico en el área de cuneros. Se

ausculta soplo sistólico sobre septum ventricular.
 ENARM
Curso Dr. Huitrón
Referring to your diagnostic impression, what is
truth?
a) It is known to be the most common cyanotic heart disease in newborns
b) It is known to be the most common cyanotic heart disease in childhood
c) It never gives symptoms before 1 year of age
d) It is not related to heart failure
 ENARM
Curso Dr. Huitrón
This pathology tends to have a very typical
radiographic finding which is called
a) Egg on string sign
b) Boot shaped heart
c) Snowman heart
d) Eight heart
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Newborn shows cyanosis and dificulty breathing moments after birth.

Shows no fever, sternal systolic murmur is found.

Recién nacido presenta cianosis y dificultad respiratoria momentos después

de nacer. No presenta fiebre, se encuentra soplo sistólico esternal.
 ENARM
Curso Dr. Huitrón
Radiographic finding usually presented in this
group of patients
a) Egg on string sign
b) Boot shaped heart
c) Snowman heart
d) Eight heart
Transposition of great vessels /
transposition of great arteries
 ENARM
Curso Dr. Huitrón

60-year-old patient in treatment with enalapril and metoprolol comes to the

ER feeling dizzy, clinical examination shows diaphoresis and bradychardia.
ECG is taken

Paciente de 60 años en tratamiento con enalapril y metoprolol acude a

urgencias sintiendo mareo, examen físico muestra diaforesis y bradicardia.
Se toma ECG
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Diagnosis for this patient

a) First degree AV block

b) Second degree AV block Mobitz 1
c) Second degree AV block Mobitz 2
d) Third degree AV block
 ENARM
Curso Dr. Huitrón

AV block
• Conduction disturbance between atrium and ventricle
• Symptomatic AV block in the abscence of a reversible cause, usually
warrants permanent pacemaker implantation
 ENARM
Curso Dr. Huitrón

22-year-old patient comes to the ER presenting palpitations, dyspnea,

diaphoresis, dizziness, and mild chest pain. ECG is taken

Paciente de 22 años acude a urgencias por palpitaciones, disnea, diaforesis,

mareo, leve dolor torácico. Se toma ECG
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Diagnosis in this case

a) Supraventricular tachycardia
b) Ventricular tachycardia
c) Atrial flutter
d) Ventricular flutter
 ENARM
Curso Dr. Huitrón

First line maneuver for this patient

a) Vagal maneuvers
b) Adenosine
c) Verapamile
d) Cardioversion
 ENARM
Curso Dr. Huitrón

If first line management fails, what comes next?

a) Vagal maneuvers
b) Adenosine
c) Verapamile
d) Cardioversion
 ENARM
Curso Dr. Huitrón

Paroxysmal supraventricular tachycardia

• Rapid, regular tachycardia, most common in Young adults
• Abrupt onset and offset
• QRS narrowed
• Often responsive to vagal maneuvers, or adenosine
• Cardioversion rarely required
 ENARM
Curso Dr. Huitrón

19-year-old patient consults over palpitations, dizziness, and mild chest pain
that have been happening randomly during the past 6 months. He first
thought to be stress. ECG was taken

Paciente de 19 años acude a consulta por palpitaciones, mareos, y dolor

torácico leve que llevan sucediendo aleatoriamente por 6 meses. El creyó
inicialmente que se trataba de tensión emocional. ECG fue tomado
 ENARM
Curso Dr. Huitrón
 ENARM
Curso Dr. Huitrón

Diagnostic impression Haz de Kent

a) Ventricular flutter
b) Atrial flutter
c) WPW
d) Right bundle Branch block
 ENARM
Curso Dr. Huitrón

Preexcitation syndrom WPW

• Short PR Interval
• Wide QRS due to preexcitation (delta wave)
• High risk of sudden cardiac death: atrial fibrillation
 ENARM
Curso Dr. Huitrón

76-year-old patient is was brought to the ER by his family. They were having
dinner when the patient showed afasia and felt to the floor. Physical
examination revealed an erratic intensity pulse. History of congestive heart
failure and hypertension. ECG was taken
Paciente de 76 años es llevado a urgencias por su familia. Se encontraban
cenando cuando el paciente mostró afasia y cayó al suelo. Examen físico
revela pulso de intensidad variable. Antecedentes de insuficiencia cardiaca
congestiva e hipertensión. Se toma ECG
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Curso Dr. Huitrón
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Curso Dr. Huitrón

Diagnosis for this patient

a) Atrial fibrillation normal ventricular response

b) Atrial fibrillation rapid ventricular response
c) Atrial flutter
d) Ventricular fibrillation
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Curso Dr. Huitrón
Your patient’s BP in undetected, indicated
management
a) Cardioversion
b) Defibrillation
c) Verapamil
d) Metoprolol
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Curso Dr. Huitrón
Would you recommend oral anticoagulation to
this patient?
a) Yes
b) No
c) Maybe
d) YOLO
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Curso Dr. Huitrón
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Curso Dr. Huitrón
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Curso Dr. Huitrón

IC over the next ECG

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Curso Dr. Huitrón

Electrocardiographical diagnosis

a) Atrial fibrillation
b) Atrial flutter
c) Ventricular fibrillation
d) Ventricular flutter
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Curso Dr. Huitrón

GRACIAS