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NBME 23 Answers

nbme23/Block 3/Question#12 (24.6 difficulty score)
A 39-year-old man comes to the physician for ...

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submitted by yotsubato(965),
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HOMC si edu to aiunmotst gidncneo scmeoerras csuh as siymon dbniing onpreit C nda ebta mnoysi ehvya acn.ih

btl_nyc  So I thought this was Marfan's because the murmur from HOCM is at the left sternal border, but Marfan's is a defect in fibrillin, not in collagen. +3  
arcanumm  To help rule out Marfran's, it is stated that there are "no history of major medical illness," which I wouldn't expect them to put if there was a syndrome going on. (they also tend to give body habitus descriptors at least) +  
dul071  This isn't HOCM, rather it's simply Mitral stenosis. He has a murmur that radiates at the apex which happens to be the Mitral area. Despite everything his BLOOD PRESSURE AND PULSE are normal. The heart is over working to keep the vitals normal and as a consequence, it is undergoing hypertrophy which dictates the answer +  
dna_at  @dull071 I don't think this is MS. That would be 1) diastolic and not systolic, 2) less likely to cause LVH. I believe as others said it is just HOCM leading to MR, which is what we are hearing. MR secondary to HOCM would still increase in intensity with less preload as there would be more LVOT obstruction (thus more regurgitation) +1  

submitted by krewfoo99(88),
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krewfoo99  Correction: Shouldnt it be heard best in the left upper sternal border? +  
usmlehulk  In FA 2018 page 303. patients with HOCM presents with MItral regurgitation due to impared mitral valve closure. Hence this explains the murmur. +1  

submitted by maxillarythirdmolar(35),
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mario  wrong q bro @ maxillarythirdmolar +  
usmile1  nope right question. he just went even deeper into the answer. +