both in inspiration and expiration. Delayed closure of the pulmonic valve due to a right bundle branch block, pulmonic stenosis, or mitral regurgitation causes a wide splitting of S2. Fixed splitting of S2 is unaffected by respiration. It is due to ASD. Paradoxical splitting of S2 is caused by anything that delays A2 or speeds up P2 to the point where P2 occurs prior to A2. For this reason, expiration, not inspiration, separates a paradoxical split by prolonging left ventricular ejection and shortening right ventricular ejection. The causes of a paradoxical split S2 are left bundle branch block and aortic stenosis, both of which prolong left ventricular outflow. 183-184. The answers are 183-b, c, d, h, 184-a, f, i. (Sapira, p 92.) Pulse pressure is calculated by subtracting systolic BP from diastolic BP. A widened pulse pressure (diastolic BP > 50% of systolic BP) is due to conditions associated with a high stroke volume, such as AI, PDA, fever, pregnancy, hyperthyroidism, beriberi, anemia, and Paget's disease. A narrowed pulse pressure (diastolic BP < 25% of systolic BP) suggests a low stroke volume and is seen in pericardial tamponade, constrictive pericarditis, AS, and tachycardia.
185-188. The answers are 185-a, 186-i, 187-l, 188-k. (Fauci, 14/e, pp 1303-1304, 1317, 1330.) Patients with AS may present with symptoms of angina, syncope, dyspnea, or congestive heart failure. The etiologies of AS include rheumatic fever and congenital bicuspid valve. Idiopathic calcific AS is a common disorder in the elderly and may produce the murmur of AS, but it is usually a mild disorder and of no significance. Hyper-trophic obstructive cardiomyopathy (HOCM or HCM) is the most common cause of sudden cardiac death in young adults. Patients may be asymptomatic, and over half have a positive family history of sudden death. ASD is a common anomaly in adults; VSD may be a congenital anomaly or a complication of myocardial infraction. Both defects may cause a left-to-right shunt, which may lead to pulmonary hypertension (loud S
2) and pulmonary obstruction (Eisenmenger syndrome).
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