View Full Version : Help Please NBME physio

06-12-2006, 11:50 AM
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

I think it might be Mitral Stenosis but not sure, also leaning towards S4

06-12-2006, 12:26 PM
I think choice #I S4 - Atrial kick associated with hypertropic ventrical with hyper tension, why not the others - first at Apex, no clue for mitral stenosis - like rheumatic heart disease or infection. Possible atrial fibrillation due to heart rate could indicate that, however BP is main clue to creating a hypertropic ventrical, other possible is aortic regurgitation but they gave no clue like water hammer pulse. Just high BP and poorly controlled hypertension.

06-12-2006, 12:28 PM
Just because I am a worry wart - check First Aid Cardiac cycle in physiology to see if you come to the same conclusion. Other feedback appreciated as I am still a newbie at this.

06-12-2006, 12:43 PM
The answer should be S4. The reason is:
1. He didn't have rheumatic heart disease, which is the most reason for mitral stenosis, not hypertension.
2. Mitral stenosis murmur occurs in mid diastolic at apex.
3. Heart failure caused by hypertension induces S4 which sounds at late diastolic.

Billy BA
06-13-2006, 07:12 PM
Hey there. The right answer is S4. Look at the clues in the question. 1) Hypertension = S4 heart sound due to pressure overload (S3 is caused by volume overload) 2) Using the Bell = low pitch (low frequency) heart sounds which are S3 or S4. The left lateral decubitis position is a distractor to get you worked up on the mitral valve answers. 3) Late diastole = S4, but other murmurs can also present in late diastole. So use that clue to back up 1 and 2.

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