WBR0534

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Serge Korjian and Yazan Daaboul, M.D.)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathophysiology
Sub Category	SubCategory::Cardiology
Prompt	[[Prompt::A 63-year-old man presents to the physician's office complaining of shortness of breath, rhythmic head nodding, and fatigue. On examination, his temperature is 37 °C (98.7 °F), heart rate is 88/min, and blood pressure is 160/60 mmHg. Cardiac auscultation is significant for a murmur. When the patient is asked to raise his hand above the level of his head, capillary pulsations of the nail beds are noted. Which of the following best describes the murmur present in this patient?]]
Answer A	AnswerA::Holosystolic high-pitched blowing murmur that radiates toward the axilla
Answer A Explanation	AnswerAExp::Murmur of mitral regurgitation is best described as a holosystolic high-pitched blowing murmur that radiates toward the axilla.
Answer B	AnswerB::Crescendo-decrescendo systolic murmur with ejection click
Answer B Explanation	[[AnswerBExp::Murmur of aortic stenosis is best described as a crescendo-decrescendo systolic murmur with ejection click that radiates to the carotids. Aortic stenosis usually manifests as a triad of dyspnea, syncope, and angina with narrow pulse pressure on physical examination.]]
Answer C	AnswerC::Rumbling late diastolic murmur with opening snap
Answer C Explanation	AnswerCExp::Murmur of mitral stenosis is best described as a rumbling late diastolic murmur with opening snap.
Answer D	AnswerD::Late systolic crescendo murmur with midsystolic click
Answer D Explanation	AnswerDExp::Murmur of mitral valve prolapse (MVP) is best described as a late systolic crescendo murmur with midsystolic click.
Answer E	AnswerE::Blowing diastolic decrescendo murmur best heard immediately after S2
Answer E Explanation	AnswerEExp::Murmur of aortic regurgitation (AR) is described as a blowing diastolic decrescendo murmur best heard immediately after S2. The patient's symptoms and findings are consistent with AR.
Right Answer	RightAnswer::E
Explanation	[[Explanation::The patient in this scenario is most likely presenting with aortic regurgitation (AR). Murmur of AR is best described as a blowing diastolic decrescendo murmur. It is usually caused by aortic root dilation, bicuspid aortic valve, rheumatic heart disease, or endocarditis. Patients with AR often have a widened pulse pressure (PP = SBP - DBP) as observed in this patient. This wide difference between systolic and diastolic pressures causes head bobbing, which is head nodding that accompanies one's heart beat (De Musset's sign). Additionally, patients with AR have positive Quincke's sign, which are pulsations in the capillary beds of the nails. Other signs include a bounding carotid pulse (Corrigan’s pulse), pulsation of the uvula (Muller’s sign), pistol-shot sounds during auscultation of the femoral artery (Traube’s sign), and bruit during compression of the femoral artery (Duroziez sign). Educational Objective: Murmur of AR is best described as a high-pitched diastolic decrescendo murmur. Patients usually present with shortness of breath, fatigue, and head bobbing (De Musset's sign). Physical examination findings include a wide pulse pressure and a positive Quincke's sign. References: Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125-34. First Aid 2014 page 273]]
Approved	Approved::Yes
Keyword	WBRKeyword::Aortic regurgitation, WBRKeyword::De Musset's sign, WBRKeyword::Quincke's sign, WBRKeyword::Head bobbing, WBRKeyword::Murmur, WBRKeyword::Aortic insufficiency, WBRKeyword::Wide pulse pressure, WBRKeyword::Physical exam, WBRKeyword::Auscultation
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::