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NBME 23 Answers

nbme23/Block 4/Question#14 (46.5 difficulty score)
A 61-year-old woman comes to the physician ...
Closure of the mitral valveπŸ”
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 +12 
submitted by lfsuarez(141),
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tisFr ehtra usdno S1() is reneategd by tow herat lasve:v teh tarilm evalv adn tirpcidus v.vlae ryaelN nsleoumasuti gslionc fo ehste avelvs rlloanym eaegnstre a snigle S1 nos.ud gSpnltiti fo the S1 uodsn is rdhea nwhe tmilra dan drpiuitcs lvsaev soelc ta lygtilsh detinffer ie,stm wiht asylulu het rmtila gscnlio erboef ritduicps

yotsubato  Then why the fuck is it describing a mitral valve sound in the tricuspid area +22  
dr.xx  it's describing a splitting S1 β€” consisting of mitral and tricuspid valve closure β€” that is best heard at the tricuspid (left lower sternal border) and mitral (cardiac apex) listening posts. +30  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +4  
titanesxvi  tricky question, I though what sound it is in the left sternal border, so I chose tricuspid valve, but what they where asking was, what is the first component of the S1 sound +1  
drzed  It shouldn't matter where you hear a split sound. For example, no matter where you auscultate on the heart, the second heart sound in a healthy individual will always be A2 then P2 (whether you are at the mitral listening post or the aortic listening post) The key is recognizing that the right sided valves in healthy individuals will always close later (e.g. the heart sounds are S1 S2, but more specifically M1 T1 A2 P2). The reason for this is simple: if you take a breath in, you will increase preload on the right side of the heart, and thus the greater volume will cause a delayed closure of the valve. This is physiologic splitting, and is better appreciated in the pulmonary and aortic valves because they are under greater pressure, and thus louder, but it can also be heard in the first heart sound. +9  
alexxxx30  yes agreed!! This question is mostly asking if you understand a few basic things regarding cardio physio. The left side of the heart is the higher pressure side so left sided valves will close first. The right side of the heart is the lower pressure side, which means right sided valves will open first. [Left closes first, Right opens first]...Secondly, it requires you to know what S1 and S2 sounds come from. S1 is the mitral/tricuspid valve closing and S2 is the Aortic/pulmonary valves closing. So really the question asks what is the first component of S1 (mitral or tricuspid closes first). And since we know that the left side will always close first, it must be mitral valve closure. Sorry if that was a long explanation. +10  
jesusisking  Thanks @alexxxx30, you the man! RIP Kobe +  



 +4 
submitted by gh889(115),
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rGaet evido no 1S nad 'sit tip!s!l




 +2 
submitted by rolubui(11),
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ehT way I ebmrreem ti, :1S Mailtr p&am; iisdtucrp bc lobdo eosg morf aairt ot eienlcstvr hnet rofm nesvrclite to isteodu het heart t&-;-g 2S. ow,N nhew you hvae a lStip 1S teh wya I ktnih oubta si htta nhew uyo haeiln you haev axret bldoo nimgco ntoi the htgir dsei fo eht hatre so hte dsptiruic elvsva scoles aetlr nad ssucae a lispt S1 uopn .siptniraeor Hpeo htta s.phle




 +1 
submitted by yogi(11),
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:Q Siltp S1 ahder roev etLf rsanelt rrebod - ipctudrsi are.a istFr cteoompnn of SA 1?: igatynnh M(C ni )BBRB hatt uecsas aydleed rucleso of icitsprud vaevl ormecpda to tlmari avv-el ilwl eusac iplst 1S thiw leadyed 1T nad ayerl 1M hdare ta iipdsTurc ra.ea




 +0 
submitted by usmlehulk(4),

Please read the last sentence of the question. I think the split might be because of Rbb,. this causes the mitral and tricuspid valve to close at different times.

-so which of the following best explains the first component of the heart sound (split S1). Should be the mitral valve closure before the tricuspid valve.