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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{Rim}}, {{AJL}} {{Alison}}
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
Line 20: Line 20:
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Cardiology
|SubCategory=Cardiology
|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 appreciated 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?
|Prompt=A 62-year-old male presents to the emergency room with complaints of progressive shortness of breath at rest.  Vital signs demonstrate a temperature of 37 °C, heart rate of 90 bpm, blood pressure of 110/70 mmHg, and respiratory rate of 30 breaths/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 most likely true regarding the patient's extra heart sound?
|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. 
|Explanation=The patient presents with symptoms suggestive of heart failure.  Physical examination of the patient reveals an extra heart sound (S3), which is described as an early diastolic heart sound occurring due to increased filling pressure in dilated ventricle.  


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.
Findings upon physical examination are associated with poor prognosis in patients with heart failure.  Elevated jugular venous pressure (JVP) and third heart sound (S3) are cardinal features in the determination of likely prognosis in patients with heart failure.  


Educational Objective: Presence of S3 is associated with worse outcomes in patients with heart failure.
|EducationalObjectives= The manifestation of S3 is associated with worse outcomes in patients with heart failure.
|References= 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.


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.
|AnswerA=The patient's extra heart sound is a result of atrial contraction against a stiff ventricle.
|AnswerA=The patient's extra heart sound is a result of atrial contraction against a stiff ventricle.
|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.
|AnswerAExp=S3 manifests due to the increased filling pressure in a dilated ventricle.  S4 is characterized by atrial contraction against a stiff ventricle.
|AnswerB=The patient's presence of an extra heart sound conveys poor prognostic outcomes.
|AnswerB=The manifestation of an extra heart sound is indicative of poor prognostic outcomes.
|AnswerBExp=The presence of S3 carries poor prognostic implications in patients with heart failure.
|AnswerBExp=The manifestation of S3 carries poor prognostic implications in patients with heart failure.
|AnswerC=The patient's symptoms are consistent with isolated left ventricular dysfunction
|AnswerC=The patient's symptoms are consistent with isolated left ventricular dysfunction
|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.
|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 implicate involvement of the right side of the heart.
|AnswerD=Aortic stenosis is another pathologic state that is commonly  characterized by the same extra heart sound as the patient.
|AnswerD=Aortic stenosis is another pathologic state that is frequently characterized by the same type of extra heart sound
|AnswerDExp=The extra heart sound that is commonly present in aortic stenosis is S4.
|AnswerDExp=The extra heart sound that frequently manifests in aortic stenosis is S4.
|AnswerE=The patient's extra heart sound is best heard at the base of the heart
|AnswerE=The patient's extra heart sound is best heard at the base of the heart
|AnswerEExp=S3 is best heard at the apex of the heart; whereas S4 is best heard at the base of the heart.
|AnswerEExp=S3 is best heard at the apex of the heart; whereas S4 is best heard at the base of the heart.
|RightAnswer=B
|RightAnswer=B
|WBRKeyword=heart, failure, cardiac, left, right, jugular, venous, distention, jugular venous distention, pressure, JVD, pitting, edema, pitting edema, third, sound, heart, third heart sound, S3, diastole, shortness, breath, shortness of breath, stiff, ventricle, dilated, apex, base
|WBRKeyword=heart failure, cardiac, jugular venous distention, JVD, pitting edema, third heart sound, S3, shortness of breath, ventricle, dilated, cardiology, respiratory system, cardiovascular system,
|Approved=No
|Approved=Yes
}}
}}

Revision as of 15:21, 30 July 2014
Author [[PageAuthor::Rim Halaby, M.D. [1], Alison Leibowitz [2] (Reviewed by Alison Leibowitz)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathophysiology
Sub Category SubCategory::Cardiology
Prompt [[Prompt::A 62-year-old male presents to the emergency room with complaints of progressive shortness of breath at rest. Vital signs demonstrate a temperature of 37 °C, heart rate of 90 bpm, blood pressure of 110/70 mmHg, and respiratory rate of 30 breaths/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 most likely 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 manifests due to the increased filling pressure in a dilated ventricle. S4 is characterized by atrial contraction against a stiff ventricle.
Answer B AnswerB::The manifestation of an extra heart sound is indicative of poor prognostic outcomes.
Answer B Explanation AnswerBExp::The manifestation 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 implicate involvement of the right side of the heart.]]
Answer D AnswerD::Aortic stenosis is another pathologic state that is frequently characterized by the same type of extra heart sound
Answer D Explanation AnswerDExp::The extra heart sound that frequently manifests 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 base of the heart.
Right Answer RightAnswer::B
Explanation [[Explanation::The patient presents with symptoms suggestive of heart failure. Physical examination of the patient reveals an extra heart sound (S3), which is described as an early diastolic heart sound occurring due to increased filling pressure in dilated ventricle.

Findings upon physical examination are associated with poor prognosis in patients with heart failure. Elevated jugular venous pressure (JVP) and third heart sound (S3) are cardinal features in the determination of likely prognosis in patients with heart failure.
Educational Objective: The manifestation of S3 is associated with worse outcomes in patients with heart failure.
References: 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.]]

Approved Approved::Yes
Keyword WBRKeyword::heart failure, WBRKeyword::cardiac, WBRKeyword::jugular venous distention, WBRKeyword::JVD, WBRKeyword::pitting edema, WBRKeyword::third heart sound, WBRKeyword::S3, WBRKeyword::shortness of breath, WBRKeyword::ventricle, WBRKeyword::dilated, WBRKeyword::cardiology, WBRKeyword::respiratory system, WBRKeyword::cardiovascular system
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