A 55-year-old hypertensive patient has a standing BP 190 /105 and sitting BP - 180/100. He also has irregularly irregular rhythm, double apical impulse and bilateral basal crepitations but no murmurs. Heart rate cannot be determined. What is the likely cause?

Ans: D (Left ventricular hypertrophy) Ref: Harrison's Principles of Internal Medicine, 18th ednExplanation:Chronic hypertension can explain High BP values. Atrial fibri Illation, LVH, double apical impulse, No murmurs and bilateral basal crepitations (due to pulmonary congestion). But not sure.Left atrial myxoma, MR or cor pulmonale atone cannot explain all symptoms.Hypertensive Heart DiseasePulsesNormal in patients in sinus rhythmTachycardia in CCFTachycardia and irregularly irregular pulse in Atrial fibrillationBlood pressure elevatedVeins: |JVP in CCFHeart:Apical ImpulseIn patients without systolic dysfunction: Sustained and non- dispiaced.In LV dysfunction, apical impulse displaced laterally due to LV dilatation.Rarely, double apical impulse.Presystolic S4 can be felt.Lungs: Signs of pulmonary congestion - Crepts and wheeze,Cause of Irregular RhythmsRegularly irregular pulseIrregularly irregular pulseSinus arrthytmiaAtrial fibrillationPulsus bigeminus due to PVCsMultifocal atrial tachycardiaPulsus alternansFrequent PVCs1st and 2nd degree heart blocks Double Apical ImpulseHOCM (both impulse occurs in systole).Myocardial infarction.Left ventricular aneurysm.Systolic dick syndrome assc with MVP.Systemic hypertension.Other OptionsMitral regurgitationPSM at apexSoft S1 Left atrial myxomaNo hypertensionTumor plopCor pulmonalePhysical findings of underlying Sung disease.RVH - Parasternal heave.RV failure - |VP, Hepatojugular reflex, Pulsatile liver.Pedal edema.