WBR0534

Author	[[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Serge Korjian)]]
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 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 in this scenario is most likely presenting with aortic regurgitation (AR). 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. This wide difference between systolic and diastolic pressures 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. Other signs include a bounding carotid pulse (Corrigan’s pulse), pulsation of the uvula (Muller’s sign), and pistol shot sounds over the femoral artery with compression (Traube’s sign). 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 includes, but are not limited to, 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.]]
Approved	Approved::Yes
Keyword	WBRKeyword::Aortic regurgitation, WBRKeyword::De Musset's sign, WBRKeyword::Quincke's sign, WBRKeyword::Head bobbing, WBRKeyword::Murmur
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::