WBR0534

Author	[[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathophysiology
Sub Category	SubCategory::Cardiology
Prompt	[[Prompt::A 63 year old male patient presents to the physician's office complaining of shortness of breath, rhythmic head nodding, and fatigue. Vital signs reveal temperature of 37 degrees C (98.7 degrees F), heart rate of 88 bpm, and blood pressure measuring 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 described as holosystolic high-pitched blowing murmur that radiates toward the axilla. The patient's symptoms and physical examination findings are more consistent with AR.
Answer B	AnswerB::Crescendo-decrescendo systolic murmur with ejection click
Answer B Explanation	[[AnswerBExp::Aortic stenosis is characterized by a crescendo-decrescendo systolic murmur with ejection click that radiate to the carotids. Aortic stenosis usually presents with a triad of dyspnea, syncope, and angina with narrow pulse pressure on physical examination. The patient's symptoms and physical examination findings are more consistent with AR.]]
Answer C	AnswerC::Rumbling late diastolic murmur with opening snap
Answer C Explanation	AnswerCExp::Mitral stenosis is described as a rumbling late diastolic murmur with opening snap. The patient's symptoms and physical examination findings are more consistent with AR.
Answer D	AnswerD::Late systolic crescendo murmur with midsystolic click
Answer D Explanation	AnswerDExp::Mitral valve prolapse murmur is described as a late systolic crescendo murmur with midsystolic click. The patient's symptoms and physical examination findings are more consistent with AR.
Answer E	AnswerE::Blowing diastolic decrescendo murmur best heard immediately after S2
Answer E Explanation	AnswerEExp::Aortic regurgitation murmur is described as a blowing diastolic decrescendo murmur best heard immediately after S2. The patient's symptoms and findings are consistent with aortic valve regurgitation.
Right Answer	RightAnswer::E
Explanation	[[Explanation::The patient most likely has aortic regurgitation (AR) that is causing the symptoms. Symptoms and physical examination findings are important clues to detect aortic regurgitation. AR is characterized by a blowing diastolic decrescendo murmur. It is usually caused by aortic root dilation, bicuspid aortic valve, rheumatic heart disease, or endocarditis. Patients with aortic regurgitation often have a widened pulse pressure (PP = SBP - DBP) as seen in this patient that causes head bobbing - head nodding accompanying one's heart beat. This is called De Musset's sign. Additionally, patients with AR have positive Quincke's sign, which are pulsations in the capillary beds of the nails. In fact, there are several signs on physical examination that are useful to diagnose AR, but routine performance of such signs has been widely replaced by echocardiogram, which is diagnostic. Educational Objective: AR is 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, include but are not exclusive to, wide pulse pressure and positive Quincke's sign. Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::aortic, WBRKeyword::regurgitation, WBRKeyword::valve, WBRKeyword::wide, WBRKeyword::widened, WBRKeyword::pulse, WBRKeyword::pressure, WBRKeyword::Quincke, WBRKeyword::sign, WBRKeyword::nail, WBRKeyword::bed, WBRKeyword::pulsating, WBRKeyword::pulsation, WBRKeyword::head, WBRKeyword::bobbing, WBRKeyword::S1, WBRKeyword::S2, WBRKeyword::crescendo, WBRKeyword::decrescendo, WBRKeyword::blowing, WBRKeyword::murmur, WBRKeyword::rumbling
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