WBR0533

Author	[[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type	ExamType::USMLE Step 1
Main Category
Sub Category	SubCategory::Cardiology
Prompt	[[Prompt::A 62 year old male patient presents to the emergency department with progressive shortness of breath at rest. Vital signs show a temperature of 37 degrees C (98.6 degrees F), a heart rate of 90 bpm, a blood pressure measuring 110/70 mmHg, and respiratory rate of 30/min. Physical examination reveals an extra heart sound in early diastole, prominent jugular vein, and pitting edema in the lower extremities. Which of the following statements is true regarding the patient's extra heart sound?]]
Answer A	AnswerA::The patient's extra heart sound is a result of atrial contraction against a stiff ventricle.
Answer A Explanation	AnswerAExp::S3 is heard due to increased filling pressure in a dilated ventricle. On the other hand, S4 is characterized by atrial contraction against a stiff ventricle.
Answer B	AnswerB::The patient's presence of an extra heart sound conveys poor prognostic outcomes.
Answer B Explanation	AnswerBExp::The presence of S3 carries poor prognostic implications in patients with heart failure.
Answer C	AnswerC::The patient's symptoms are consistent with isolated left ventricular dysfunction
Answer C Explanation	[[AnswerCExp::The patient's syndrome, characterized by shortness of breath, JVD, S3 on cardiac auscultation, and pitting edema is consistent with heart failure of both the left and the right sides. JVD and pitting edema are important signs that implicate the involvement of the right side of the heart.]]
Answer D	AnswerD::Aortic stenosis is another pathologic state that is commonly characterized by the same extra heart sound as the patient.
Answer D Explanation	AnswerDExp::The extra heart sound that is commonly present in aortic stenosis is S4.
Answer E	AnswerE::The patient's extra heart sound is best heard at the base of the heart
Answer E Explanation	AnswerEExp::S3 is best heard at the apex of the heart; whereas S4 is best heard at the apex of the heart.
Right Answer	RightAnswer::B
Explanation	[[Explanation::The patient is presenting with symptoms consistent with heart failure. Physical examination of the patient reveals an extra heart sound, S3, that is described as early diastolic heart sound that occurs in the context of increased filling pressure in dilated ventricle. The patient also has jugular venous distention and pitting edema of the lower extremities, both of which signify the presence of right-sided involvement vs. the shortness of breath that signifies the involvement of the left side of the heart in this patient as well. Physical examination findings are associated with poor prognosis and worse outcomes in patients with heart failure. Elevation jugular venous pressure (JVP) and third heart sound (S3) are 2 physical examination findings that are considered cardinal features of the determination of prognosis in patients with heart failure. Patients with presence of S3 sound are more likely to have worse New York Heart Association (NYHA) functional class than those with absent S3 sound. Educational Objective: Presence of S3 is associated with worse outcomes in patients with heart failure. Reference: Rame JE, Dies DL, Dranzer MH, et al. The prognostic value of the physical examination in patients with chronic heart failure. Congestive Heart Failure. 2007;9(3):170-5, 178. Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::heart, WBRKeyword::failure, WBRKeyword::cardiac, WBRKeyword::left, WBRKeyword::right, WBRKeyword::jugular, WBRKeyword::venous, WBRKeyword::distention, WBRKeyword::jugular venous distention, WBRKeyword::pressure, WBRKeyword::JVD, WBRKeyword::pitting, WBRKeyword::edema, WBRKeyword::pitting edema, WBRKeyword::third, WBRKeyword::sound, WBRKeyword::heart, WBRKeyword::third heart sound, WBRKeyword::S3, WBRKeyword::diastole, WBRKeyword::shortness, WBRKeyword::breath, WBRKeyword::shortness of breath, WBRKeyword::stiff, WBRKeyword::ventricle, WBRKeyword::dilated, WBRKeyword::apex, WBRKeyword::base
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