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NBME 24 Answers

nbme24/Block 4/Question#38 (reveal difficulty score)
A 33-year-old woman at 34 weeks' gestation ...
Stroke volume ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
tags: cardio hy weird

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 +16  upvote downvote
submitted by โˆ—sympathetikey(1600)
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Would've been nice if they told you "2nd intercostal space" on left or right...smh

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paperbackwriter  It wouldn't have mattered because the murmur is due to increased stroke volume, not anything mechanically wrong with the valves. If they had said A or P then it might have actually caused more confusion (stenosis etc.) +7
cport12  Also an important side note is that with the addition of the placenta, systemic vascular resistance would actually decrease (another organ added in parallel) which should help point you towards an increase in stroke volume. +1



 +11  upvote downvote
submitted by โˆ—seagull(1933)
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"Blood flow to various organs increases during pregnancy to meet the increased metabolic needs of tissues. Thus, venous return and cardiac output increases dramatically during pregnancy. Cardiac output gradually increases during the first 2 trimesters with the largest increase occurring by 16 weeks of gestation.3 The increase in cardiac output is well established by 5 weeks of gestation and increases to 50% above prepregnancy levels by 16 to 20 weeks of gestation. The rise in cardiac output typically plateaus after 20 weeks of gestation and remains elevated until term. The increases in cardiac output are associated with significant increases in stroke volume and heart rate (HR)"

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3802121/

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 +8  upvote downvote
submitted by โˆ—m-ice(370)
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A soft systolic murmur is common in many pregnant women due to a high volume of flow (increased cardiac output). The murmur tends to go away within a few weeks of delivery once the cardiac output is closer to baseline.

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 +4  upvote downvote
submitted by โˆ—sunshinesweetheart(112)
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p 619 FA 2019 - physiologic changes in pregnancy

incr CO, anemia, hypercoagulability, hyperventilation, incr lipoylsis and fat utilization to preserve glucose and AAs for the baby

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 +2  upvote downvote
submitted by โˆ—usmle11a(102)
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my way was

SV =EDV-ESV

EDV increases in pregnancy due to an increase in plasma volume

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 +1  upvote downvote
submitted by โˆ—step420(32)
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I have a question: Since CO = SV * HR, and in pregnancy, women have an increased basal HR, why can't the answer be Pulse?

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home_run_ball  I don't think HR would explain the grade 2/6 murmur, but SV would +4



 -4  upvote downvote
submitted by โˆ—neonem(629)
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My best guess is that this patient has a bicuspid aortic valve and has a murmur due to increased volume overload from the pregnancy.

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charcot_bouchard  Can be congenital mild Tricuspid stenosis also. it also exaggerate during preg +
noplanb  Wouldn't Tricuspid stenosis be a systolic murmur? +
noplanb  I mean diastolic* +1
centeno  I think that a murmur of grade 2/6 is a clue for flow murmur. Maybe any pathologic cause of murmur would be exaggerated in pregnancy (due to increased blood volume) +
srmtn  "Although a heart murmur and ankle swelling may be associated with heart disease, these two symptoms also may occur during a normal pregnancy. Nearly 90 percent of pregnant women develop a heart murmur, which may be due to the increased volume of blood flowing through the heart during pregnancy." +



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