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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor= {{YD}} (Reviewed by Serge Korjian and  {{YD}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Cardiology
|SubCategory=Cardiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
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|MainCategory=Pathophysiology
|MainCategory=Pathophysiology
|SubCategory=Cardiology
|SubCategory=Cardiology
|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?
|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?
|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.
|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).
 
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.
 
|AnswerA=Holosystolic high-pitched blowing murmur that radiates toward the axilla
|AnswerA=Holosystolic high-pitched blowing murmur that radiates toward the axilla
|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.
|AnswerAExp=Murmur of mitral regurgitation is best described as a holosystolic high-pitched blowing murmur that radiates toward the axilla.
|AnswerB=Crescendo-decrescendo systolic murmur with ejection click
|AnswerB=Crescendo-decrescendo systolic murmur with ejection click
|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.
|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.
|AnswerC=Rumbling late diastolic murmur with opening snap
|AnswerC=Rumbling late diastolic murmur with opening snap
|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.
|AnswerCExp=Murmur of mitral stenosis is best described as a rumbling late diastolic murmur with opening snap.
|AnswerD=Late systolic crescendo murmur with midsystolic click
|AnswerD=Late systolic crescendo murmur with midsystolic click
|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.
|AnswerDExp=Murmur of mitral valve prolapse (MVP) is best described as a late systolic crescendo murmur with midsystolic click.
|AnswerE=Blowing diastolic decrescendo murmur best heard immediately after S2
|AnswerE=Blowing diastolic decrescendo murmur best heard immediately after S2
|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.
|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.
|EducationalObjectives=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.<br>
First Aid 2014 page 273
|RightAnswer=E
|RightAnswer=E
|WBRKeyword=aortic, regurgitation, valve, wide, widened, pulse, pressure, Quincke, sign, nail, bed, pulsating, pulsation, head, bobbing, S1, S2, crescendo, decrescendo, blowing, murmur, rumbling
|WBRKeyword=Aortic regurgitation, De Musset's sign, Quincke's sign, Head bobbing, Murmur, Aortic insufficiency, Wide pulse pressure, Physical exam, Auscultation
|Approved=No
|Approved=Yes
}}
}}

Latest revision as of 00:52, 28 October 2020

 
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::