WBR0534

Author	[[PageAuthor::Rim Halaby, M.D. [1], Alison Leibowitz [2] (Reviewed by Alison Leibowitz)]]
Exam Type	ExamType::USMLE Step 1
Main Category	MainCategory::Pathophysiology
Sub Category	SubCategory::Cardiology
Prompt	[[Prompt::A 63-year-old male presents to the physician's office with complaints of shortness of breath, rhythmic head nodding, and fatigue. Vital signs reveal a temperature of 37 °C, heart rate of 88 bpm, and blood pressure measuring 160/60 mmHg. Cardiac auscultation is significant for a murmur and 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::A mitral regurgitation murmur is a holosystolic high-pitched blowing murmur that radiates toward the axilla. The patient's symptoms and 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 manifest with a triad of dyspnea, syncope, and angina with narrow pulse pressure upon physical examination. The patient's symptoms and examination findings are more consistent with AR.]]
Answer C	AnswerC::Rumbling late diastolic murmur with opening snap
Answer C Explanation	AnswerCExp::Mitral stenosis is is characterized by a rumbling late diastolic murmur with opening snap. The patient's symptoms and 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 characterized by a late systolic crescendo murmur with midsystolic click. The patient's symptoms and examination findings are more consistent with AR.
Answer E	AnswerE::Blowing diastolic decrescendo murmur best heard immediately after S2
Answer E Explanation	AnswerEExp::See overall explanation.
Right Answer	RightAnswer::E
Explanation	[[Explanation::The patient most likely has aortic regurgitation (AR). Symptoms and physical examination findings aid in the detection of aortic regurgitation, which is characterized by a blowing diastolic decrescendo murmur that 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), leading to head bobbing (head nodding accompanying one's heart beat), referred to as De Musset's sign. Additionally, patients with AR demonstrate Quincke's sign, pulsations in the capillary beds of the nails. Echocardiogram is diagnostic. Educational Objective: AR is described as a high-pitched diastolic decrescendo murmur. Patients with AR frequently present with shortness of breath, fatigue, and head bobbing (De Musset's sign). AR is also associated with wide pulse pressure and positive Quincke's sign. References: First Aid 2014 page 243]]
Approved	Approved::Yes
Keyword	WBRKeyword::aortic regurgitation, WBRKeyword::valve, WBRKeyword::pulse, WBRKeyword::Quincke sign, WBRKeyword::nail bed, WBRKeyword::pulsation, WBRKeyword::head bobbing, WBRKeyword::S1, WBRKeyword::S2, WBRKeyword::crescendo, WBRKeyword::decrescendo, WBRKeyword::cardiovascular system, WBRKeyword::cardiology, WBRKeyword::heart
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::