NBME Cardio question

[bludeviled]

Advertisement - Members don't see this ad

A 50-year-old man has a 10-year history of poorly controlled hypertension. Vital signs are:

Pulse 96/min
Respirations 16/min
Blood pressure
Left arm 226/120 mm Hg
Right arm 218/118 mm Hg

With the patient in the left lateral decubitus position, a late diastolic sound is heard best with the bell at the apex. Which of the following is the most likely explanation for this auscultatory finding?
A) Aortic insufficiency
B) Aortic stenosis
C) Mitral insufficiency
D) Mitral stenosis
E) Opening snap
F) Pulmonic insufficiency
G) Pulmonic stenosis
H) S3
I) S4
J) Tricuspid insufficiency
-------------
first off - why the right vs. left difference? I thought only a dissection could do that ( or maybe sometimes a coarct). Also the huge pulse pressures (seen in aortic stenosis but the bell at the apex doesn't sound like aortic stenosis)

I picked S4 perhaps due to LV hypertrophy - but I'm not sure about that

Anyone have the right answer and why? - thank ya much

 

[mellow yellow]

A 50-year-old man has a 10-year history of poorly controlled hypertension. Vital signs are:

Pulse 96/min
Respirations 16/min
Blood pressure
Left arm 226/120 mm Hg
Right arm 218/118 mm Hg

With the patient in the left lateral decubitus position, a late diastolic sound is heard best with the bell at the apex. Which of the following is the most likely explanation for this auscultatory finding?
A) Aortic insufficiency
B) Aortic stenosis
C) Mitral insufficiency
D) Mitral stenosis
E) Opening snap
F) Pulmonic insufficiency
G) Pulmonic stenosis
H) S3
I) S4
J) Tricuspid insufficiency
-------------
first off - why the right vs. left difference? I thought only a dissection could do that ( or maybe sometimes a coarct). Also the huge pulse pressures (seen in aortic stenosis but the bell at the apex doesn't sound like aortic stenosis)

I picked S4 perhaps due to LV hypertrophy - but I'm not sure about that

Anyone have the right answer and why? - thank ya much

The BP difference in the arms are negligible and within normal limits.

S4 is correct. The clinical history of long-standing, poorly controlled hypertension as well as the current elevated pressures suggest that he should have a noncompliant ventricle and likely has some degree of diastolic dysfunction. S4 is a late diastolic sound and heard best in the LLD position. So yes, S4 is correct.

In addition, large pulse pressures are seen characteristically in AI, NOT AS. The current pulse pressure is not that large, relatively speaking, as both systolic and diastolic are markedley high.

 

[bludeviled]

[Quote
In addition, large pulse pressures are seen characteristically in AI, NOT AS. The current pulse pressure is not that large, relatively speaking, as both systolic and diastolic are markedley high.[/QUOTE]

Thanks mellow yellow
oops
my bad - you're right about AS vs. AI; but the pulse pressure is around 100 - thats pretty high, don't you think? But i think i see what you're saying b/c the diastolic is still pretty high so it couldn't be AI
----------------------------
Here are some more questions if anyone will kindly take a stab at them:

2. In gout, hyperuricemia resulting from overproduction of urate is most likely to result from a lack of feedback inhibition by ADP or GDP at which enzyme?

a. adenosine deaminase, b.dihydrofolate reductase, c. glucose 6phosphate dehydrogenase, d. necleotide phosphorylase, e. phosphoribosylpyrophosphate synthetase


3. A 45 year old woman has an acute coronary occlusion. within seconds the ischemic region shows mitochondrial swelling and depletion of glycogen granules. which of the following metabolic events is the most likely cause of these cellular changes?

a. accumulation of free fatty acids, b. ATP depletion, c. degradation of membrane phospholipid, d. efflux of K+. e. infflux of Na+


4. A sexually active 18year old woman comes to the physician's office because of fever, lower abdominal pain, and a purulent vaginal discharge for the last 3 weeks. A tender mass is palpated in the right lower quadrant on bimanual examination. wihich fo the following is the most likely site of the mass?

a. ovary, b. fallopian tube, c. uterine fundus, d. uterine body, e. vagina, f. bladder, g. rectum

I put E, B, and B but I'm having some doubts

 

[Idiopathic]

You are right on all three of those questions.

As far as pulse pressure, four things raise pulse pressure above 60 or so, that I know of: a) anxiety, b) hyperthyroid, c) anemia/sepsis, d) AI. 100 is a significant PP, but as mello points out, the higher your systemic pressures, the less significant an elevated PP becomes. 150/50 is much more important than 220/120.

 

[kaboodle]

How would you differentiate between S4 and mitral stenosis?

A 50-year-old man has a 10-year history of poorly controlled hypertension. Vital signs are:

Pulse 96/min
Respirations 16/min
Blood pressure
Left arm 226/120 mm Hg
Right arm 218/118 mm Hg

With the patient in the left lateral decubitus position, a late diastolic sound is heard best with the bell at the apex. Which of the following is the most likely explanation for this auscultatory finding?
A) Aortic insufficiency
B) Aortic stenosis
C) Mitral insufficiency
D) Mitral stenosis
E) Opening snap
F) Pulmonic insufficiency
G) Pulmonic stenosis
H) S3
I) S4
J) Tricuspid insufficiency
-------------
first off - why the right vs. left difference? I thought only a dissection could do that ( or maybe sometimes a coarct). Also the huge pulse pressures (seen in aortic stenosis but the bell at the apex doesn't sound like aortic stenosis)

I picked S4 perhaps due to LV hypertrophy - but I'm not sure about that

Anyone have the right answer and why? - thank ya much

 

[Idiopathic]

For me:

The sound isn't 'classic' MS, i.e. early to mid-diastolic snap, and is instead a 'late-diastolic sound'. I think lying down would make the MS murmur come earlier anyway, d/t increased preload. Also, the hx of 10 years of poorly controlled HTN...S4 is more likely here than MS, I believe.