USMLE Forum - Largest USMLE Community

A 55-year-old man complains of 6 months of shortness
of breath. He has new dyspnea on exertion and threepillow
orthopnea. Lung auscultation reveals rales 2/3 bilaterally.
He has 2+ pitting lower extremity edema. Jugular
venous pressure is estimated to be 14 cmH20 measured at
a 45° angle. Chest radiograph reveals pulmonary infiltrates
and an enlarged cardiac silhouette. Electrocardiography
shows low-voltage in the precordial and limb leads.
An echocardiogram shows a dilated left ventricle, ejection
fraction of 20%, mild mitral regurgitation, and a small
pericardial effusion. Which finding on cardiac examination
would be consistent with this patient's diagnosis?
A. Absent S2
B. Narrow pulse pressure
C. Paradoxical splitting of S2 with inspiration
D. Pulsus bisferiens

BB

bbb

D?

BBB

whts the ans,
CHF

bbbbbb

The answer is B.Varying degrees of cardiac enlargement and findings of
congestion can be found in patients with dilated cardiomyopathies, depending on the
chronicity of the illness. In severe left ventricular dilatation, the jugular venous pressure is
elevated, murmurs of mitral and tricuspid regurgitation are common, and third or fourth
heart sounds may be heard. Owing to the depressed cardiac output, systemic vascular resistance
increases, and with it, diastolic blood pressure. Systolic blood pressure may decrease
as a result of decreased cardiac output leading to a narrow pulse pressure.
Conditions in which S2 becomes absent include severe aortic stenosis and severe aortic insufficiency
when the insufficiency murmur is louder than S2. Paradoxical splitting occurs
when P2 and A2 become closer during inspiration and can be seen in patients with left
bundle branch block. Pulsus bisferiens (double-impulse pulse) is classically detected when
aortic insufficiency exists in association with aortic stenosis, but it may also be found