1/11. endocarditis attributable to group A beta-hemolytic streptococcus after uncomplicated varicella in a vaccinated child.Varicella is generally a benign, self-limited childhood illness; however, severe, life-threatening complications do occur. A live, attenuated vaccine exists to prevent this illness, but controversy remains concerning the need to vaccinate children for what is generally a benign, self-limited disease, although more states are currently recommending this vaccine. We report a previously healthy 3-year-old who developed varicella 6 months after vaccination with no apparent skin superinfections, who subsequently developed group A beta-hemolytic streptococcus (GABHS) bacteremia resulting in endocarditis of a normal heart valve. We are unaware of previous reports of endocarditis related to GABHS after varicella. After developing a harsh, diastolic murmur that led to an echocardiogram, aortic valve endocarditis was diagnosed. A 6-week course of intravenous penicillin g was administered. Two weeks after the initiation of therapy, the diastolic murmur was harsher, and echocardiography revealed a large vegetation on the posterior leaflet of the aortic valve, with severe aortic insufficiency and a dilated left ventricle. The patient subsequently developed congestive heart failure requiring readmission and aggressive management. One month after the initial echocardiogram, a repeat examination revealed worsening aortic regurgitation and mitral regurgitation. The patient received an additional 4 weeks of intravenous penicillin and gentamicin followed by aortic valve replacement using the Ross procedure. Our patient, the first reported case of bacteremia and endocarditis from GABHS after varicella, illustrates the need for the health care practitioner to consider both common and life-threatening complications in patients with varicella. While cellulitis, encephalitis, and septic arthritis may be readily apparent on physical examination and commonly recognized complications of varicella, the possibility of bacteremia without an obvious skin superinfection should also be entertained. The case we report is unique in that the patient had normal immune function, had been previously vaccinated, and developed a rare complication of varicella-endocarditis-in a structurally normal heart with a previously unreported pathogen. Although a child may have been vaccinated against varicella, the chance of contracting the virus still exists and parents should be informed of this risk. group A beta-hemolytic streptococcus, endocarditis, varicella, Varivax, complications of varicella.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/11. Aortic subannular left ventricular aneurysm in a patient of Asian ancestry.An asymptomatic 50-year-old Japanese man was diagnosed with an aortic subannular left ventricular aneurysm during a routine physical checkup. Operative findings showed the subaortic aneurysm had developed beneath the noncoronary cusp of the aortic valve and expanded into the epicardium between the aortic root and left atrium. The operation involved patch closure of the orifice of the annular subaortic aneurysm, aortic valvuloplasty, and plication of the dilated ascending aorta.- - - - - - - - - - ranking = 0.10914428126282keywords = physical (Clic here for more details about this article) |
3/11. eponyms and the diagnosis of aortic regurgitation: what says the evidence?BACKGROUND: Chronic aortic regurgitation can lead to significant morbidity and mortality. For more than a century, numerous eponymous signs of aortic regurgitation have been described in textbooks and the literature. PURPOSE: To compare current textbook content with the peer-reviewed literature on the eponymous signs of aortic regurgitation and to assess the role of these signs in clinical practice. DATA SOURCES: 11 textbooks, medline (1966 through October 2002), and bibliographies of textbooks and relevant papers. STUDY SELECTION: English-language reports that were related to the properties of a sign on physical examination, incorporated more than 10 adults, and did not involve prosthetic heart valves or acute aortic regurgitation. DATA EXTRACTION: Three investigators independently analyzed relevant textbook extracts and 27 reports, using predetermined qualitative review criteria. Data relating to diagnostic accuracy and properties of the index test were also extracted. DATA SYNTHESIS: Twelve eponymous signs were described as having varying degrees of importance by textbook authors. Only the Austin Flint murmur, the Corrigan pulse, the Duroziez sign, and the Hill sign had sufficient original literature for detailed review. Most reports were low quality, with varying sensitivities for all signs. Except for the Hill sign, specificity tended to be poor. Evidence for the Hill sign also suggested a correlation between the popliteal-brachial gradient and aortic regurgitation severity. CONCLUSIONS: Prominent textbook support of the eponymous signs of aortic regurgitation is not matched by the literature. Clinicians and educators should update and improve the evidence for these signs to ensure their relevance in current medical practice.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
4/11. The heart as a bass organ.Many florid physical signs of aortic regurgitation have been described. We describe a florid investigational finding of virtually monotonous intracardiac reverberation originating at the aortic valve leaflets.- - - - - - - - - - ranking = 0.10914428126282keywords = physical (Clic here for more details about this article) |
5/11. Large ascending aortic aneurysm and severe aortic regurgitation in a 7-year-old child with marfan syndrome and a review of the literature. marfan syndrome in childhood.A 7-year-old girl was admitted because of dyspnea on exertion and palpitations. Her symptoms had gradually worsened for the last 6 months. She had physical features of the marfan syndrome. Transthoracic echocardiography showed an ascending aortic aneurysm, severe aortic regurgitation, and mildly dilated left ventricle. Because of marked aortic aneurysm and severe aortic regurgitation, the patient was treated with a beta-blocker and an angiotensin converting enzyme inhibitor. Surgery was refused by her parents. We describe here a child with marfan syndrome in whom significant dilatation of the ascending aorta and severe aortic regurgitation is encountered and major cardiovascular complications of marfan syndrome were reviewed.- - - - - - - - - - ranking = 0.10914428126282keywords = physical (Clic here for more details about this article) |
6/11. Replacement of a severe chronic post-traumatic aneurysm of the ascending aorta with aortic valve conduit--reconstruction of the anterior mitral valve ring and implantation of A-V sequential/biventricular pacemaker.We present the case of a 23-year-old African professional footballer who was admitted on April 1, 1999 to the cardiology Department of the University Hospital in Magdeburg, on an emergency basis, from a regional lung clinic. According to the history, he was involved in a collision with an opposing player during a football match in his country (in africa). He lost consciousness for a short time, but continued playing to the end of the match. About two months later he was invited by a German football club for a check-up, with the view to ultimately playing for the club. The team did not find him physically fit enough to play professional football, so he decided to go to paris by bus on March 31, 1999. During the journey he suddenly became cardio-pulmonary decompensated and had to undergo cardio-pulmonary resuscitation (CPR). He was intubated and placed on a respirator and immediately transferred to a nearby lung clinic. From the lung clinic he was transferred to the intensive care Unit of the cardiology Department of the Magdeburg University Hospital, on April 1, 1999 as an emergency case. He was intensively treated with catecholamines, intravenous ACE inhibitors and diuretics. His clinical condition did not improve appreciably. His chest X-ray showed extreme dilatation of the right and left heart as well as extreme pulmonary congestion.- - - - - - - - - - ranking = 0.10914428126282keywords = physical (Clic here for more details about this article) |
7/11. Congenital aortic regurgitation: natural history and management.OBJECTIVES AND BACKGROUND. Congenital aortic regurgitation is rare as an isolated lesion. We describe seven children with no physical features of the marfan syndrome in the patients or their families and no other cardiac lesions who had congenital valvular aortic regurgitation. methods. From 1954 to the present, seven children with auscultatory and physiologic characteristics of aortic regurgitation were evaluated for a total of 108 patient-years. We report on their natural history, clinical and laboratory findings, management and outcome. RESULTS. In five of the seven children congenital aortic regurgitation was diagnosed in infancy. In four, progressive severity of the regurgitation led to valve replacement at age 3, 10, 15 and 20 years, respectively, and to resection of an aneurysm of the ascending aorta in the 10-year old patient. Two patients had cystic medial necrosis on aortic biopsy. One of these patients died after reoperation for dissecting aneurysm of the thoracic aorta at 22 years of age; the other died after dissection and rupture of the ascending aorta at age 25 years. After obstructing pannus developed, the 3-year old patient underwent replacement of the St. Jude valve at age 10 years. The other three patients were asymptomatic at last follow-up at age 8, 10 and 20 years, respectively. CONCLUSIONS. Supportive management is recommended until it becomes necessary to intervene surgically when regurgitation becomes severe. The need for surgical treatment is indicated by the appearance of a diastolic thrill, left ventricular strain on the electrocardiogram or other evidence of left ventricular dysfunction on the echocardiogram or exercise stress testing by treadmill or radionuclide cineangiocardiography. Close follow-up of these patients is important to detect progression of aortic regurgitation, especially in the presence of cystic medial necrosis.- - - - - - - - - - ranking = 0.10914428126282keywords = physical (Clic here for more details about this article) |
8/11. Aortic leaflet perforation during radiofrequency ablation.A 15-year-old girl underwent successful radiofrequency ablation of an accessory pathway. Following ablation, a new III/VI diastolic murmur was noted. Echocardiography revealed a perforated aortic leaflet, with a small amount of adherent valvular tissue and trivial aortic insufficiency by color Doppler. The patient remains asymptomatic. We are not aware of any similar complication from electrophysiological study, catheter ablation, coronary angiography, or percutaneous transluminal coronary angioplasty. We speculate that the current state of catheter technology contributed significantly to this complication. This case illustrates the need for using care in crossing the valve, continued advances in catheter technology to reduce the incidence of complications, and careful physical examination prior to and following attempts at ablation.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
9/11. Management of valvular heart disease: an illustrative cases approach.As indicated by the 22 illustrative cases included in this monograph, a stepwise approach to the assessment of valvular heart disease provides the information necessary to make good clinical decisions. The ECG and chest x-ray add useful information to the history and physical examination. echocardiography, doppler, and color flow Doppler techniques have an important role in defining the presence and severity of valvular stenosis and regurgitation. Nuclear techniques provide useful information about global biventricular systolic function, regional wall motion, and myocardial perfusion. Exercise testing is most valuable in confirming objectively the patient's functional status and exercise tolerance. Newer imaging techniques, such as cine CT and MRI, are capable of displaying and measuring cardiac chamber size and myocardial thickness; however, visualization of the cardiac valves and demonstration of flow abnormalities are difficult, limiting the current usefulness of these techniques in patients with valvular heart disease.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
10/11. Acute severe aortic regurgitation. Pathophysiology, clinical recognition, and management.Acute severe aortic regurgitation is a relatively unfamiliar, though life-threatening, disease. We review its diverse causes, anatomic faults, and hemodynamic sequelae and set the stage for an understanding of the clinical manifestations in light of their physiologic mechanisms. Clinical information includes the natural history, physical signs (physical appearance, systemic arterial pulse, jugular venous pulse, precordial palpation, auscultation), electrocardiogram, and chest roentgenogram. Echocardiographic features are especially emphasized and the need for prompt diagnosis and surgical intervention underscored, even in the setting of active infective endocarditis.- - - - - - - - - - ranking = 0.21828856252563keywords = physical (Clic here for more details about this article) |
| | Next -> |