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NBME 20 Answers

nbme20/Block 1/Question#42 (reveal difficulty score)
A 60-year-old man has two-pillow orthopnea, ...
Jugular venous pressure of 12 mm Hg ๐Ÿ” / ๐Ÿ“บ / ๐ŸŒณ / ๐Ÿ“–
tags: cardio

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 +25  upvote downvote
submitted by โˆ—yotsubato(1208)

Bifid carotid pulses are seen in Aortic stenosis or regurgitation

Carotid Bruit is heard with atherosclerosis of common carotid artery

Slow rising decreased volume carotid pulse is characteristic of aortic stenosis.

Cannon waves are seen in complete AV block, as right ventricle and atria contract independently.

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chextra  I mis-remembered normal JVP as 8-12. Therefore, I picked "Slow-rising, decreased-volume carotid pulse". Is there a reason why this is NOT a result of HF, or is it simply not the best (which I agree is JVD)? +1
len49  For those wondering normal JVP is 6-8 mmHg +5
fatboyslim  @chextra I think the reason why it's NOT slow-rising decreased-volume carotid pulse (sign of aortic stenosis) is because the patient had a h/o prolonged substernal chest pain 5 days ago. I think he had an MI and is now presenting w/ heart failure. +1

 +11  upvote downvote
submitted by โˆ—hayayah(1212)

This patient has heart failure. Normal JVP is 6-8 mmHg.

Signs of heart failure are based on cardiac pump dysfunction, ยŽcongestion, and low perfusion.

Symptoms: include dyspnea, orthopnea, fatigue; signs include S3 heart sound, rales, jugular venous distention (JVD), and pitting edema.

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 +1  upvote downvote
submitted by scpomp(2)

Cannon A waves occur when the right atrium contracts against a closed tricuspid valve. Classically seen in AV dissociation (complete heart block).

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 +0  upvote downvote
submitted by โˆ—dickass(127)

Patient has acutely decompensated heart failure, most likely due to an MI 5 days ago. Orthopnea-dyspnea-edema would mean he likely also has jugular venous distention and hepatic congestion.

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