Usha L. is a 16 year-old male who attended a routine follow up visit at his family doctor’s office. He would like to start playing competitive soccer and the coach asked for a doctor’s clearance. The patient’s family was pleased with the proactive approach the coach demonstrated, as they were also worried about the small but real risk of sudden collapse sometimes resulting in death in young elite athletes without previous diagnosis of heart disease. The coach was particularly concerned about ruling out any type of heart disease. Usha is active, athletic and asymptomatic. His past medical history is unremarkable. There is no family history of cardiac disease. He doesn’t smoke or use street drugs.

To discuss and to practice the components of the Cardiac history and physical examination.

To discuss and to practice the components of the Cardiac history and physical examination.

A 10-day-old infant is brought to the emergency room of your hospital by his mother with a history of progressive irritability and poor breastfeeding. On history, the infant was born by uncomplicated spontaneous vaginal delivery at 40 weeks gestation following a completely unremarkable pregnancy. Birth weight was 3.5 kg. The infant was well after birth and breast feeding was initiated by his mother without any problems. He was discharged home on day 2 of life. Over the subsequent days, the infant had increasing irritability and poor feeding; his mother describes him as having more difficulty at the breast, sucking for only a few seconds and then seeming short of breath. She also notices that he seems to be getting more tired and that his lips turn purple during feeding. In the emergency room, the baby is irritable and cyanotic-looking. Vital signs show a respiratory rate of 36 breaths per minute, heart rate of 195 bpm; BP 75/30 mmHg; oxygen saturation 75% on room air. He is noted to be warm and well perfused, but persistently cyanotic. On exam, he has palpable femoral pulses bilaterally, and normal breath sounds. Lung fields are clear to auscultation. He has a harsh systolic murmur best appreciated on the left upper sternal border. You provide 100% oxygen by face mask and order bloodwork, EKG and a chest X-ray.

A 10-day-old infant is brought to the emergency room of your hospital by his mother with a history of progressive irritability and poor breastfeeding. On history, the infant was born by uncomplicated spontaneous vaginal delivery at 40 weeks gestation following a completely unremarkable pregnancy. Birth weight was 3.5 kg. The infant was well after birth and breast feeding was initiated by his mother without any problems. He was discharged home on day 2 of life. Over the subsequent days, the infant had increasing irritability and poor feeding; his mother describes him as having more difficulty at the breast, sucking for only a few seconds and then seeming short of breath. She also notices that he seems to be getting more tired and that his lips turn purple during feeding. In the emergency room, the baby is irritable and cyanotic-looking. Vital signs show a respiratory rate of 36 breaths per minute, heart rate of 195 bpm; BP 75/30 mmHg; oxygen saturation 75% on room air. He is noted to be warm and well perfused, but persistently cyanotic. On exam, he has palpable femoral pulses bilaterally, and normal breath sounds. Lung fields are clear to auscultation. He has a harsh systolic murmur best appreciated on the left upper sternal border. You provide 100% oxygen by face mask and order bloodwork, EKG and a chest X-ray.

Wael M. is a 78-year-old man who is brought to the emergency room after collapsing at the casino. The last thing he recalls before losing consciousness is drawing an ace while sitting at the blackjack table. His past medical history is unremarkable and he is on no medications. On arrival to the ER, his heart rate is 30 bpm with a blood pressure of 80/50 mmHg. He is alert and oriented, but feels lightheaded. His JVP is not elevated, but cannon a-waves are occasionally seen. There are no carotid bruits. The remainder of the physical examination, including a neurological examination, is normal. In the ER, a temporary transvenous pacemaker is inserted via the right internal jugular vein and positioned into the right ventricular apex. The pacemaker is turned on and set to pace at 60 bpm. At this rate, Wael M.'s BP increases to 100/70 mmHg and his light-headedness resolves. The next morning, Wael M. has a dual chamber permanent pacemaker inserted. His 12-lead EKG post implant shows paced ventricular beats with a left bundle branch block pattern.

Wael M. is a 78-year-old man who is brought to the emergency room after collapsing at the casino. The last thing he recalls before losing consciousness is drawing an ace while sitting at the blackjack table. His past medical history is unremarkable and he is on no medications. On arrival to the ER, his heart rate is 30 bpm with a blood pressure of 80/50 mmHg. He is alert and oriented, but feels lightheaded. His JVP is not elevated, but cannon a-waves are occasionally seen. There are no carotid bruits. The remainder of the physical examination, including a neurological examination, is normal. In the ER, a temporary transvenous pacemaker is inserted via the right internal jugular vein and positioned into the right ventricular apex. The pacemaker is turned on and set to pace at 60 bpm. At this rate, Wael M.'s BP increases to 100/70 mmHg and his light-headedness resolves. The next morning, Wael M. has a dual chamber permanent pacemaker inserted. His 12-lead EKG post implant shows paced ventricular beats with a left bundle branch block pattern.

Janet Woo is a 50-year-old woman with a history of intermittent palpitations. Over the last five years, she can recall infrequent and transient episodes of her heart "pounding in her chest". These episodes would not produce any other symptoms and would last no longer than a couple of minutes at a time, so she never sought medical attention. Earlier this evening, while watching television, she developed palpitations that did not resolve. She became diaphoretic, felt dizzy and somewhat short of breath and so called 911 and was brought to the ER.

Janet Woo is a 50-year-old woman with a history of intermittent palpitations. Over the last five years, she can recall infrequent and transient episodes of her heart "pounding in her chest". These episodes would not produce any other symptoms and would last no longer than a couple of minutes at a time, so she never sought medical attention. Earlier this evening, while watching television, she developed palpitations that did not resolve. She became diaphoretic, felt dizzy and somewhat short of breath and so called 911 and was brought to the ER.

Novak B. is a 55-year-old man with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia. He presents himself at your office because he has been experiencing chest pain for several days, but has been reluctant to come to the office. He first noted it 6 weeks ago while shoveling snow. The discomfort was mid-sternal and radiated to his jaw. It resolved with rest. Since then, he has noted 3 similar episodes each occurring while climbing the 2 flights of stairs from his basement to the bedroom. Upon further questioning, he also tells you that he feels cramps in both of his calves whenever he walks for more than 500 meters. If he stops walking, his symptoms resolve within 2-3 minutes. On examination, he is mildly obese. His pedal artery and posterior tibial artery pulses are significantly decreased in volume bilaterally. The remainder of the examination is normal. You diagnose him with angina and prescribe aspirin, a beta-blocker, a statin and nitroglycerin. You also make a referral to a dietician.

Novak B. is a 55-year-old man with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia. He presents himself at your office because he has been experiencing chest pain for several days, but has been reluctant to come to the office. He first noted it 6 weeks ago while shoveling snow. The discomfort was mid-sternal and radiated to his jaw. It resolved with rest. Since then, he has noted 3 similar episodes each occurring while climbing the 2 flights of stairs from his basement to the bedroom. Upon further questioning, he also tells you that he feels cramps in both of his calves whenever he walks for more than 500 meters. If he stops walking, his symptoms resolve within 2-3 minutes. On examination, he is mildly obese. His pedal artery and posterior tibial artery pulses are significantly decreased in volume bilaterally. The remainder of the examination is normal. You diagnose him with angina and prescribe aspirin, a beta-blocker, a statin and nitroglycerin. You also make a referral to a dietician.

Novak B. is a 55-year-old man with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia. He presents himself at your office because he has been experiencing chest pain for several days, but has been reluctant to come to the office. He first noted it 6 weeks ago while shoveling snow. The discomfort was mid-sternal and radiated to his jaw. It resolved with rest. Since then, he has noted 3 similar episodes each occurring while climbing the 2 flights of stairs from his basement to the bedroom. Upon further questioning, he also tells you that he feels cramps in both of his calves whenever he walks for more than 500 meters. If he stops walking, his symptoms resolve within 2-3 minutes. On examination, he is mildly obese. His pedal artery and posterior tibial artery pulses are significantly decreased in volume bilaterally. The remainder of the examination is normal. You diagnose him with angina and prescribe aspirin, a beta-blocker, a statin and nitroglycerin. You also make a referral to a dietician.

Three years have now gone by and Novak B. has done very well. He has used his Nitroglycerin only once since you prescribed it, when he had to run for a bus. One night, you happen to be working an ER night shift at the local hospital when Novak is brought in by an ambulance. He is complaining of severe retrosternal chest pain, which started one hour ago. An EKG is obtained immediately and confirms an acute myocardial infarction (AMI). A chest X-ray is normal, as is his first Troponin T. You give him 162 mg of aspirin to chew, along with 180 mg of ticagrelor and enoxaparin 80 mg subcutaneously every 12 hours, as a starting dose. On examination, he is in distress from the pain and looks dyspneic. His pulse is 90 bpm and his respiratory rate is 24. His blood pressure is 100/70 mmHg in both arms. His O2 saturation is 90% on 2L oxygen via nasal prongs. His JVP is 5 cm above the sternal angle. He has bibasilar inspiratory crackles. His heart sounds are obscured by the ambient noise in the ER, but no obvious murmurs are heard. He has no peripheral edema. You briefly discuss percutaneous coronary intervention (PCI) and thrombolytic therapy. Novak does not consent to thrombolysis, but agrees to PCI.

Novak B. was discharged home following his myocardial infarction. He felt well for 4 days. He then developed an episode of dull retrosternal chest pain lasting for 2 hours. He felt this was somewhat different than the chest pain he had presented to hospital with during his MI. He felt unwell and was pale and diaphoretic on arrival at the ER. In the ER, his BP dropped to 85/55 mmHg, RR 32, HR 135 bpm, his JVP was elevated at 10 cm above the sternal angle. His lungs were clear to auscultation. Precordial examination demonstrated soft heart sounds. An EKG demonstrated sinus tachycardia with generalized low voltages and no new ST segment abnormalities. An echocardiogram was performed immediately and demonstrated a large pericardial effusion.

Sade A. is a 54-year-old woman known to have hypertrophic cardiomyopathy. She was diagnosed at age 18 when she had a syncopal episode. She was told to avoid any competitive or physically demanding sports. Her brother was also diagnosed with the same condition. Her echocardiograms have shown increased septal thickness and obstruction to flow at the left ventricular outflow level. She is on metoprolol to decrease the degree of outflow obstruction. She was well until a few weeks prior to consultation when she started to feel her heart racing and felt frequent irregular heartbeats. Since then, her heart rate has been consistently around 110-120 bpm. She has also noticed effort intolerance. She used to be able to walk her dog, but now she becomes short of breath as soon as she reaches an incline and has to slow down. On exam, her heart rate is 105-110 bpm and irregular, blood pressure 118/68 mmHg, JVP is not elevated, she is acyanotic. You can hear crackles at both lung bases, no peripheral edema, precordial exam reveals a sustained apical impulse and a grade 3/6 systolic murmur which increases with the Valsalva maneuver.

Three years have now gone by and Novak B. has done very well. He has used his Nitroglycerin only once since you prescribed it, when he had to run for a bus. One night, you happen to be working an ER night shift at the local hospital when Novak is brought in by an ambulance. He is complaining of severe retrosternal chest pain, which started one hour ago. An EKG is obtained immediately and confirms an acute myocardial infarction (AMI). A chest X-ray is normal, as is his first Troponin T. You give him 162 mg of aspirin to chew, along with 180 mg of ticagrelor and enoxaparin 80 mg subcutaneously every 12 hours, as a starting dose. On examination, he is in distress from the pain and looks dyspneic. His pulse is 90 bpm and his respiratory rate is 24. His blood pressure is 100/70 mmHg in both arms. His O2 saturation is 90% on 2L oxygen via nasal prongs. His JVP is 5 cm above the sternal angle. He has bibasilar inspiratory crackles. His heart sounds are obscured by the ambient noise in the ER, but no obvious murmurs are heard. He has no peripheral edema. You briefly discuss percutaneous coronary intervention (PCI) and thrombolytic therapy. Novak does not consent to thrombolysis, but agrees to PCI.

Novak B. is a 55-year-old man with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia. He presents himself at your office because he has been experiencing chest pain for several days, but has been reluctant to come to the office. He first noted it 6 weeks ago while shoveling snow. The discomfort was mid-sternal and radiated to his jaw. It resolved with rest. Since then, he has noted 3 similar episodes each occurring while climbing the 2 flights of stairs from his basement to the bedroom. Upon further questioning, he also tells you that he feels cramps in both of his calves whenever he walks for more than 500 meters. If he stops walking, his symptoms resolve within 2-3 minutes. On examination, he is mildly obese. His pedal artery and posterior tibial artery pulses are significantly decreased in volume bilaterally. The remainder of the examination is normal. You diagnose him with angina and prescribe aspirin, a beta-blocker, a statin and nitroglycerin. You also make a referral to a dietician.

Novak B. is a 55-year-old man with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia. He presents himself at your office because he has been experiencing chest pain for several days, but has been reluctant to come to the office. He first noted it 6 weeks ago while shoveling snow. The discomfort was mid-sternal and radiated to his jaw. It resolved with rest. Since then, he has noted 3 similar episodes each occurring while climbing the 2 flights of stairs from his basement to the bedroom. Upon further questioning, he also tells you that he feels cramps in both of his calves whenever he walks for more than 500 meters. If he stops walking, his symptoms resolve within 2-3 minutes. On examination, he is mildly obese. His pedal artery and posterior tibial artery pulses are significantly decreased in volume bilaterally. The remainder of the examination is normal. You diagnose him with angina and prescribe aspirin, a beta-blocker, a statin and nitroglycerin. You also make a referral to a dietician.

Novak B. is a 55-year-old man with a history of type 2 diabetes mellitus, hypertension and hyperlipidemia. He presents himself at your office because he has been experiencing chest pain for several days, but has been reluctant to come to the office. He first noted it 6 weeks ago while shoveling snow. The discomfort was mid-sternal and radiated to his jaw. It resolved with rest. Since then, he has noted 3 similar episodes each occurring while climbing the 2 flights of stairs from his basement to the bedroom. Upon further questioning, he also tells you that he feels cramps in both of his calves whenever he walks for more than 500 meters. If he stops walking, his symptoms resolve within 2-3 minutes. On examination, he is mildly obese. His pedal artery and posterior tibial artery pulses are significantly decreased in volume bilaterally. The remainder of the examination is normal. You diagnose him with angina and prescribe aspirin, a beta-blocker, a statin and nitroglycerin. You also make a referral to a dietician.

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Amanda VP. is a 44-year-old Russian immigrant whom you first meet at family health team where you are completing your core training as a family medicine resident. Amanda presents to the clinic because she’s had a two-week history of fevers, chills, malaise and shortness of breath on exertion. She became particularly concerned earlier today when she experienced a brief episode of left arm weakness that lasted for approximately 5 minutes and then completely resolved. Amanda, one of four children, grew up in the former Soviet Union, in a poor household with her extended family (cousins, aunt and uncle, and grandparents). Amanda VP.’s short stature makes you wonder if she was malnourished as a child and if so, what other effects this may have had on her health. Her past medical history seems unremarkable. She has been hospitalized once when she delivered healthy twin girls twenty years ago. She does recall having been told by her obstetrician that she had a heart murmur. She is married and works as a dental assistant in her husband's office. She smokes one pack of cigarettes daily and has done so for 30 years. She does not drink alcohol. On examination, she looks unwell. She is febrile with a temperature of 38.8 degrees Celsius. Her heart rate is 110 bpm with a BP of 100/65 mmHg. Head and neck examination reveals bilateral conjunctival petechiae. Her JVP is 4 cm above the sternal angle. Her chest is clear. Heart sounds reveal a grade 3/6 pan-systolic murmur best heard at the apex and an S3 with gallop. Her point of maximal impulse is enlarged and palpated in the anterior axillary line. She has mild bilateral pedal edema. Neurological examination, including fundoscopy, is completely normal as is the dermatologic exam. You decide to admit her to hospital, order blood work, a chest X-ray, and an echocardiogram.

Terrance K. is a 60-year-old gentleman who comes to the emergency room after experiencing an episode of retrosternal chest discomfort. This occurred while he was walking on his treadmill at home. The pain was mid-sternal, non-radiating, and resolved approximately two minutes after he stopped his treadmill. He admits to several recent episodes of similar chest discomfort, each occurring during exercise. His first episode occurred 6 months ago, though they have become more frequent over the last month. He has noted these episodes only with exertion and never at rest. He became particularly alarmed with today's episode because he also felt quite lightheaded and thought he was going to faint. His past medical history is unremarkable, though he admits to not having been to a doctor in over 30 years. He is on no medications and denies any drug allergies. On examination, his heart rate is 76 bpm and regular, his BP is 110/70 mmHg, and his respiratory rate is 12. He is afebrile with a temperature of 36.8 degrees Celsius. His JVP is elevated at 5 cm above the sternal angle. His carotid pulse is somewhat delayed and with a diminished upstroke. There is a palpable thrill over both carotids. His chest reveals bibasilar crackles on auscultation. His cardiac exam reveals a sustained but not displaced point of maximal impulse. There is a palpable S4. The first heart sound is normal though the second heart sound is diminished in intensity. There is an easily heard fourth heart sound. There is also a harsh, grade 3/6, crescendo-decrescendo systolic murmur that peaks late in systole. The murmur radiates into both subclavian arteries as well as both carotids. It is also heard throughout the precordium.

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Amanda VP. is a 44-year-old Russian immigrant whom you first meet at family health team where you are completing your core training as a family medicine resident. Amanda presents to the clinic because she’s had a two-week history of fevers, chills, malaise and shortness of breath on exertion. She became particularly concerned earlier today when she experienced a brief episode of left arm weakness that lasted for approximately 5 minutes and then completely resolved. Amanda, one of four children, grew up in the former Soviet Union, in a poor household with her extended family (cousins, aunt and uncle, and grandparents). Amanda VP.’s short stature makes you wonder if she was malnourished as a child and if so, what other effects this may have had on her health. Her past medical history seems unremarkable. She has been hospitalized once when she delivered healthy twin girls twenty years ago. She does recall having been told by her obstetrician that she had a heart murmur. She is married and works as a dental assistant in her husband's office. She smokes one pack of cigarettes daily and has done so for 30 years. She does not drink alcohol. On examination, she looks unwell. She is febrile with a temperature of 38.8 degrees Celsius. Her heart rate is 110 bpm with a BP of 100/65 mmHg. Head and neck examination reveals bilateral conjunctival petechiae. Her JVP is 4 cm above the sternal angle. Her chest is clear. Heart sounds reveal a grade 3/6 pan-systolic murmur best heard at the apex and an S3 with gallop. Her point of maximal impulse is enlarged and palpated in the anterior axillary line. She has mild bilateral pedal edema. Neurological examination, including fundoscopy, is completely normal as is the dermatologic exam. You decide to admit her to hospital, order blood work, a chest X-ray, and an echocardiogram.

Terrance K. is a 60-year-old gentleman who comes to the emergency room after experiencing an episode of retrosternal chest discomfort. This occurred while he was walking on his treadmill at home. The pain was mid-sternal, non-radiating, and resolved approximately two minutes after he stopped his treadmill. He admits to several recent episodes of similar chest discomfort, each occurring during exercise. His first episode occurred 6 months ago, though they have become more frequent over the last month. He has noted these episodes only with exertion and never at rest. He became particularly alarmed with today's episode because he also felt quite lightheaded and thought he was going to faint. His past medical history is unremarkable, though he admits to not having been to a doctor in over 30 years. He is on no medications and denies any drug allergies. On examination, his heart rate is 76 bpm and regular, his BP is 110/70 mmHg, and his respiratory rate is 12. He is afebrile with a temperature of 36.8 degrees Celsius. His JVP is elevated at 5 cm above the sternal angle. His carotid pulse is somewhat delayed and with a diminished upstroke. There is a palpable thrill over both carotids. His chest reveals bibasilar crackles on auscultation. His cardiac exam reveals a sustained but not displaced point of maximal impulse. There is a palpable S4. The first heart sound is normal though the second heart sound is diminished in intensity. There is an easily heard fourth heart sound. There is also a harsh, grade 3/6, crescendo-decrescendo systolic murmur that peaks late in systole. The murmur radiates into both subclavian arteries as well as both carotids. It is also heard throughout the precordium.

Amanda VP. is a 44-year-old Russian immigrant whom you first meet at family health team where you are completing your core training as a family medicine resident. Amanda presents to the clinic because she’s had a two-week history of fevers, chills, malaise and shortness of breath on exertion. She became particularly concerned earlier today when she experienced a brief episode of left arm weakness that lasted for approximately 5 minutes and then completely resolved. Amanda, one of four children, grew up in the former Soviet Union, in a poor household with her extended family (cousins, aunt and uncle, and grandparents). Amanda VP.’s short stature makes you wonder if she was malnourished as a child and if so, what other effects this may have had on her health. Her past medical history seems unremarkable. She has been hospitalized once when she delivered healthy twin girls twenty years ago. She does recall having been told by her obstetrician that she had a heart murmur. She is married and works as a dental assistant in her husband's office. She smokes one pack of cigarettes daily and has done so for 30 years. She does not drink alcohol. On examination, she looks unwell. She is febrile with a temperature of 38.8 degrees Celsius. Her heart rate is 110 bpm with a BP of 100/65 mmHg. Head and neck examination reveals bilateral conjunctival petechiae. Her JVP is 4 cm above the sternal angle. Her chest is clear. Heart sounds reveal a grade 3/6 pan-systolic murmur best heard at the apex and an S3 with gallop. Her point of maximal impulse is enlarged and palpated in the anterior axillary line. She has mild bilateral pedal edema. Neurological examination, including fundoscopy, is completely normal as is the dermatologic exam. You decide to admit her to hospital, order blood work, a chest X-ray, and an echocardiogram.

Terrance K. is a 60-year-old gentleman who comes to the emergency room after experiencing an episode of retrosternal chest discomfort. This occurred while he was walking on his treadmill at home. The pain was mid-sternal, non-radiating, and resolved approximately two minutes after he stopped his treadmill. He admits to several recent episodes of similar chest discomfort, each occurring during exercise. His first episode occurred 6 months ago, though they have become more frequent over the last month. He has noted these episodes only with exertion and never at rest. He became particularly alarmed with today's episode because he also felt quite lightheaded and thought he was going to faint. His past medical history is unremarkable, though he admits to not having been to a doctor in over 30 years. He is on no medications and denies any drug allergies. On examination, his heart rate is 76 bpm and regular, his BP is 110/70 mmHg, and his respiratory rate is 12. He is afebrile with a temperature of 36.8 degrees Celsius. His JVP is elevated at 5 cm above the sternal angle. His carotid pulse is somewhat delayed and with a diminished upstroke. There is a palpable thrill over both carotids. His chest reveals bibasilar crackles on auscultation. His cardiac exam reveals a sustained but not displaced point of maximal impulse. There is a palpable S4. The first heart sound is normal though the second heart sound is diminished in intensity. There is an easily heard fourth heart sound. There is also a harsh, grade 3/6, crescendo-decrescendo systolic murmur that peaks late in systole. The murmur radiates into both subclavian arteries as well as both carotids. It is also heard throughout the precordium.

Alessandra W. is a 70-year-old lady referred to you for shortness of breath. She was previously fairly healthy until 2 months ago when she began noticing mild dyspnea with walking one to two blocks, climbing two flights of stairs, and while swimming at her local pool. Her symptoms have progressed since then to the point where she was forced to give up her swimming, which she had been doing regularly for the last several years. She also could no longer climb more than one flight of stairs without stopping. Over the last few days, she has noticed swelling in her ankles. She has become particularly concerned because she has been waking up at night short of breath and for the first time yesterday was forced to sleep sitting in her recliner. She denies any chest pain, fever, or cough.

Sade A. is a 54-year-old woman known to have hypertrophic cardiomyopathy. She was diagnosed at age 18 when she had a syncopal episode. She was told to avoid any competitive or physically demanding sports. Her brother was also diagnosed with the same condition. Her echocardiograms have shown increased septal thickness and obstruction to flow at the left ventricular outflow level. She is on metoprolol to decrease the degree of outflow obstruction. She was well until a few weeks prior to consultation when she started to feel her heart racing and felt frequent irregular heartbeats. Since then, her heart rate has been consistently around 110-120 bpm. She has also noticed effort intolerance. She used to be able to walk her dog, but now she becomes short of breath as soon as she reaches an incline and has to slow down. On exam, her heart rate is 105-110 bpm and irregular, blood pressure 118/68 mmHg, JVP is not elevated, she is acyanotic. You can hear crackles at both lung bases, no peripheral edema, precordial exam reveals a sustained apical impulse and a grade 3/6 systolic murmur which increases with the Valsalva maneuver.

Novak B. was discharged home following his myocardial infarction. He felt well for 4 days. He then developed an episode of dull retrosternal chest pain lasting for 2 hours. He felt this was somewhat different than the chest pain he had presented to hospital with during his MI. He felt unwell and was pale and diaphoretic on arrival at the ER. In the ER, his BP dropped to 85/55 mmHg, RR 32, HR 135 bpm, his JVP was elevated at 10 cm above the sternal angle. His lungs were clear to auscultation. Precordial examination demonstrated soft heart sounds. An EKG demonstrated sinus tachycardia with generalized low voltages and no new ST segment abnormalities. An echocardiogram was performed immediately and demonstrated a large pericardial effusion.

A 10-day-old infant is brought to the emergency room of your hospital by his mother with a history of progressive irritability and poor breastfeeding. On history, the infant was born by uncomplicated spontaneous vaginal delivery at 40 weeks gestation following a completely unremarkable pregnancy. Birth weight was 3.5 kg. The infant was well after birth and breast feeding was initiated by his mother without any problems. He was discharged home on day 2 of life. Over the subsequent days, the infant had increasing irritability and poor feeding; his mother describes him as having more difficulty at the breast, sucking for only a few seconds and then seeming short of breath. She also notices that he seems to be getting more tired and that his lips turn purple during feeding. In the emergency room, the baby is irritable and cyanotic-looking. Vital signs show a respiratory rate of 36 breaths per minute, heart rate of 195 bpm; BP 75/30 mmHg; oxygen saturation 75% on room air. He is noted to be warm and well perfused, but persistently cyanotic. On exam, he has palpable femoral pulses bilaterally, and normal breath sounds. Lung fields are clear to auscultation. He has a harsh systolic murmur best appreciated on the left upper sternal border. You provide 100% oxygen by face mask and order bloodwork, EKG and a chest X-ray.

A 10-day-old infant is brought to the emergency room of your hospital by his mother with a history of progressive irritability and poor breastfeeding. On history, the infant was born by uncomplicated spontaneous vaginal delivery at 40 weeks gestation following a completely unremarkable pregnancy. Birth weight was 3.5 kg. The infant was well after birth and breast feeding was initiated by his mother without any problems. He was discharged home on day 2 of life. Over the subsequent days, the infant had increasing irritability and poor feeding; his mother describes him as having more difficulty at the breast, sucking for only a few seconds and then seeming short of breath. She also notices that he seems to be getting more tired and that his lips turn purple during feeding. In the emergency room, the baby is irritable and cyanotic-looking. Vital signs show a respiratory rate of 36 breaths per minute, heart rate of 195 bpm; BP 75/30 mmHg; oxygen saturation 75% on room air. He is noted to be warm and well perfused, but persistently cyanotic. On exam, he has palpable femoral pulses bilaterally, and normal breath sounds. Lung fields are clear to auscultation. He has a harsh systolic murmur best appreciated on the left upper sternal border. You provide 100% oxygen by face mask and order bloodwork, EKG and a chest X-ray.

Embryology of the heart. Mediastinum. Pericardium. Heart chambers and valves. Auscultation of the cardiac valves. Echocardiogram. Coronary vessels. Coronary arteries and veins. Coronary artery origins. Coronary sinus. Cardiac conduction system. Autonomic innervation of the heart.

Embryology of the heart. Mediastinum. Pericardium. Heart chambers and valves. Auscultation of the cardiac valves. Echocardiogram. Coronary vessels. Coronary arteries and veins. Coronary artery origins. Coronary sinus. Cardiac conduction system. Autonomic innervation of the heart.

Embryology of the heart. Mediastinum. Pericardium. Heart chambers and valves. Auscultation of the cardiac valves. Echocardiogram. Coronary vessels. Coronary arteries and veins. Coronary artery origins. Coronary sinus. Cardiac conduction system. Autonomic innervation of the heart.

Embryology of the heart. Mediastinum. Pericardium. Heart chambers and valves. Auscultation of the cardiac valves. Echocardiogram. Coronary vessels. Coronary arteries and veins. Coronary artery origins. Coronary sinus. Cardiac conduction system. Autonomic innervation of the heart.

Usha L. is a 16 year-old male who attended a routine follow up visit at his family doctor’s office. He would like to start playing competitive soccer and the coach asked for a doctor’s clearance. The patient’s family was pleased with the proactive approach the coach demonstrated, as they were also worried about the small but real risk of sudden collapse sometimes resulting in death in young elite athletes without previous diagnosis of heart disease. The coach was particularly concerned about ruling out any type of heart disease. Usha is active, athletic and asymptomatic. His past medical history is unremarkable. There is no family history of cardiac disease. He doesn’t smoke or use street drugs.

Wael M. is a 78-year-old man who is brought to the emergency room after collapsing at the casino. The last thing he recalls before losing consciousness is drawing an ace while sitting at the blackjack table. His past medical history is unremarkable and he is on no medications. On arrival to the ER, his heart rate is 30 bpm with a blood pressure of 80/50 mmHg. He is alert and oriented, but feels lightheaded. His JVP is not elevated, but cannon a-waves are occasionally seen. There are no carotid bruits. The remainder of the physical examination, including a neurological examination, is normal. In the ER, a temporary transvenous pacemaker is inserted via the right internal jugular vein and positioned into the right ventricular apex. The pacemaker is turned on and set to pace at 60 bpm. At this rate, Wael M.'s BP increases to 100/70 mmHg and his light-headedness resolves. The next morning, Wael M. has a dual chamber permanent pacemaker inserted. His 12-lead EKG post implant shows paced ventricular beats with a left bundle branch block pattern.