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  #1  
Old 04-09-2011
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Stethoscope The heart sound in this lady!

A 65-year-old woman presents to her primary care physician with complaints of shortness of breath and a chronic cough. She has suffered idiopathic pulmonary fibrosis for several years. 10 years ago she was diagnosed with atrial fibrillation for which she's taking Amiodarone. She has been told that she should not take Digoxin if she develops hear failure. She has coarse rales throughout both lung fields and a prominent, widely-split second heart sound. Which of the following is an accurate description of the second heart sound in this patient?

A) Aortic then pulmonic valve closure
B) Aortic then pulmonic valve opening
C) Pulmonic then aortic valve opening
D) Pumonic then aortic valve closure

Note) this question is written by me and am not copying it from any other source.
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  #2  
Old 04-09-2011
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First two heart sounds = SAP*

S for S1
A for aortic valve
P for pulmonic valve

Only exceptions are with aortic stenosis or Left bundle branch block (paradoxical splitting) --> Pulmonic first then Aortic


Sounds normally occur when valves close.

So I choose A
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  #3  
Old 04-09-2011
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Default A

A, definitely.

Just out of curiosity - why are we treating an Afib patient with amiodarone - I know it may stop AV conduction but it is definitely far from first line. Also - amiodarone in a patient who *already* has pulmonary fibrosis? Here's a picture of pulmonary fibrosis *caused* by amiodarone... Are you trying to emphasize that the patient definitely will have heart failure due to the fibrosis in the lungs and therefore we see the splitting of the heart sounds?


Thanks for the question in any case. My objection has nothing to do with the question, but I was just curious as to why you chose this drug of all the possible drugs to give this patient. Also - what is the purpose of the comment about digoxin? I know again, that older sedentary patients with Afib are prescribed digoxin to improve Cardiac output but I don't get why you put it in the question

Thanks again!
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  #4  
Old 04-09-2011
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Correct Answer Correct Answer is D

The lady developed fibrosis perhaps because of the use of Amiodarone.
Although Amiodarone is not the first choice for aFib but it's not uncommonly you see patients kept on it.
The "no digoxin" hint should alert you to Wolf Parkinson White syndrome which is the origin of her AF.
In WPW you have early activation of the right atrium and therefore earlier than usual closure of the pulmonary valve and therefore reverse splitting of the S2 -- P2/A2 instead of the normal A2/P2 sequence.
Therefore the correct answer is D.
The more common reverse splitting is due to delayed aortic closure (rather than early pulmonary closure as in this case). The most common cause of delayed aortic closure is aortic stenosis.
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  #5  
Old 04-09-2011
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Wow tricky question. Was not expecting that answer at all. Good teaching question though.

Never heard that WPW can cause paradoxical splitting. I tried looking this up and couldn't find it anywhere. Where did you read about it?
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Old 04-09-2011
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Ahh - now the question makes more sense. I think I thought the fibrosis was somehow involved in the pathology afib not the other way around.

Thanks. Interesting question.
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