A 2-year-old girl is brought to the physician by her mother for a well-child examination. Cardiac auscultation is shown. When she clenches her fist forcefully for a sustained time, the intensity of the murmur increases. Which of the following is the most likely cause of this patient's auscultation findings?

Defect in the ventricular septum

Failure of the ductus arteriosus to close

Fusion of the right and left coronary leaflets

A 61-year-old man comes to the physician because of a 3-month history of fatigue and progressively worsening shortness of breath that is worse when lying down. Recently, he started using two pillows to avoid waking up short of breath at night. Examination shows a heart murmur. A graph with the results of cardiac catheterization is shown. Given this patient's valvular condition, which of the following murmurs is most likely to be heard on cardiac auscultation?

High-pitched, holosystolic murmur that radiates to the axilla

High-frequency, diastolic murmur heard best at the 2nd left intercostal space

Harsh, late systolic murmur that radiates to the carotids

Blowing, early diastolic murmur heard best at the Erb point

Rumbling, delayed diastolic murmur heard best at the cardiac apex

A 47-year-old man presents for a routine physical examination as part of an insurance medical assessment. He has no complaints and has no family history of cardiac disease or sudden cardiac death. His blood pressure is 120/80 mm Hg, temperature is 36.7°C (98.1°F), and pulse is 75/min and is regular. On physical examination, he appears slim and his cardiac apex beat is of normal character and non-displaced. On auscultation, he has a midsystolic click followed by a late-systolic high-pitched murmur over the cardiac apex. On standing, the click and murmur occur earlier in systole, and the murmur is of increased intensity. While squatting, the click and murmur occur later in systole, and the murmur is softer in intensity. Echocardiography of this patient will most likely show which of the following findings?

Prolapse of a mitral valve leaflet of ≥2 mm above the level of the annulus in systole

Left atrial mass arising from the region of the septal fossa ovalis

Doming of the mitral valve leaflets in diastole

Retrograde blood flow into the right atrium

High pressure gradient across the aortic valve

A 32-year-old male presents for a new patient visit. He states that he is in good health but has had decreasing exercise tolerance and increased levels of shortness of breath over the past 5 years. He believed that it was due to aging; he has not seen a doctor in 10 years. On auscultation, you note an early diastolic decrescendo blowing murmur that radiates along the left sternal border. In the United States, what is the most likely cause of this patient's condition?

Congenital bicuspid aortic valve

A 43-year-old man presents to his primary care physician for his yearly check-up exam. He has no new concerns but wants to make sure that his hypertension and diabetes are properly controlled. His past medical history is otherwise unremarkable and his only medications are metformin and lisinopril. He has smoked a pack of cigarettes per day since he was 16 years of age and drinks 3 beers per night. Physical exam is remarkable for a murmur best heard in the 5th intercostal space at the left mid-clavicular line. The murmur is high-pitched and blowing in character and can be heard throughout systole. Which of the following properties is characteristic of this patient's most likely disorder?

Radiation of murmur to the axilla

Results in mixing of blood between left and right ventricles

Radiation of murmur to the right sternal border

Radiation of murmur to the neck

A 7-year-old boy is brought to the pediatrician by his parents for a routine checkup. The parents note that the patient recently joined a baseball team and has had trouble keeping up with his teammates and gets short of breath with exertion. The patient has otherwise been healthy and has no known history of asthma or allergic reaction. Today, the patient’s temperature is 98.2°F (36.8°C), blood pressure is 112/72 mmHg, pulse is 70/min, and respirations are 12/min. The physical exam is notable for a heart murmur that decreases when the patient bears down. Additionally, the hand grip and rapid squatting maneuvers increase the severity of the murmur. Which of the following is likely heard on auscultation?

Holosystolic murmur at the lower left sternal border

Continuous murmur inferior to the left clavicle

Holosystolic murmur at the apex radiating to the axilla

Crescendo-decrescendo systolic murmur radiating to carotids

Late systolic murmur with a midsystolic click

A 34-year-old male is brought to the emergency department. He has prior hospitalizations for opiate overdoses, but today presents with fever, chills, rigors and malaise. On physical exam vitals are temperature: 100.5 deg F (38.1 deg C), pulse is 105/min, blood pressure is 135/60 mmHg, and respirations are 22/min. You note the following findings on the patient's hands (Figures A and B). You note that as the patient is seated, his head bobs with each successive heart beat. Which of the following findings is most likely present in this patient?

A water-hammer pulse when palpating the radial artery

A holosystolic murmur at the 4th intercostal midclavicular line

Decreased blood pressure as measured in the lower extremities compared to the upper extremities

A harsh crescendo-decrescendo systolic murmur in the right second intercostal space

A consistent gallop with an S4 component

Valvular heart disease for USMLE Step 3: High-Yield Internal Medicine Lessons

VHD Basics - The Squeaky Leaky Gates

Wiggers Diagram: Mitral Valve Stenosis Pressure Changes

Stenosis (Squeaky Gate): Narrowed valve obstructs forward flow, causing a pressure gradient ($↑ΔP$). Leads to pressure overload & concentric hypertrophy.
Regurgitation/Insufficiency (Leaky Gate): Valve doesn't close, causing backflow. Leads to volume overload & eccentric hypertrophy.
Murmurs are turbulent blood flow sounds.

⭐ Dynamic Auscultation: Maneuvers that ↑ preload (squatting, leg raise) generally ↑ murmur intensity, except in HOCM and MVP click/murmur. Handgrip (↑ afterload) ↑ regurgitant murmurs (AR, MR, VSD).

Aortic Valve Dramas - The Pressure Cooker & Blowback

Aortic Stenosis (AS): Pressure Cooker
- LV outflow obstruction → concentric LV hypertrophy.
- 📌 SAD Triad: Syncope, Angina, Dyspnea on exertion.
- Systolic crescendo-decrescendo murmur radiating to carotids.
Aortic Regurgitation (AR): Blowback
- Backflow → LV volume overload → eccentric hypertrophy.
- Diastolic, high-pitched, blowing murmur.
- Wide pulse pressure ($↑P_{systolic} - ↓P_{diastolic}$), water-hammer pulse.

⭐ Heyde's Syndrome: Aortic stenosis can cause acquired von Willebrand disease, leading to GI bleeding from angiodysplasia.

Mitral Valve Mishaps - The Rumbling Domino & Floppy Flap

Echocardiogram: Mitral Stenosis Hockey Stick Appearance

Mitral Stenosis (MS) - The Rumbling Domino
- Etiology: Chronic rheumatic heart disease is the primary cause.
- Auscultation: Loud S1, an opening snap after S2, followed by a low-pitched mid-diastolic rumble.
- Pathophys: Valve leaflets thicken and fuse → obstructs LV inflow → ↑LA pressure.
Mitral Regurgitation (MR) & Prolapse (MVP) - The Floppy Flap
- Etiology: MVP (myxomatous degeneration), ischemic damage, infective endocarditis.
- Auscultation:
  - MVP: Mid-systolic click, may have a late systolic murmur.
  - MR: Holosystolic murmur, radiates to the axilla.

⭐ Ortner's Syndrome: Severe mitral stenosis can cause massive left atrial enlargement, which may compress the left recurrent laryngeal nerve, leading to hoarseness.

Right-Sided & MVP Quirks - The Other Valves

Tricuspid Regurgitation (TR): Holosystolic murmur at left lower sternal border. Common causes: RV dilation, infective endocarditis (esp. IVDU). 📌 Right-sided murmurs ↑ with Inspiration.
Pulmonic Stenosis (PS): Harsh, systolic ejection murmur ± click at left upper sternal border. Usually a congenital defect (e.g., Tetralogy of Fallot).
Mitral Valve Prolapse (MVP): Mid-systolic click, late systolic murmur. Due to myxomatous degeneration.

⭐ MVP Maneuvers: Standing/Valsalva (↓ preload) → click is earlier, murmur is longer. Squatting (↑ preload) → click is later, murmur is shorter.

MVP murmur changes with dynamic maneuvers

Murmur Maneuvers - Shifting Sounds & Squats

Maneuver	Action	Most Murmurs	HOCM / MVP
Valsalva, Standing	↓ Preload	↓ Intensity	↑ Intensity
Squatting, Leg Raise	↑ Preload	↑ Intensity	↓ Intensity
Handgrip	↑ Afterload	↑ AR, MR, VSD	↓ HOCM, AS

📌 Think: A smaller, emptier ventricle (↓ preload) worsens the outflow obstruction in HOCM and increases prolapse in MVP.

High-Yield Points - ⚡ Biggest Takeaways

Aortic Stenosis presents with the classic triad of Syncope, Angina, and Dyspnea (SAD).

Mitral Stenosis is almost always due to rheumatic fever and features an opening snap.

Aortic Regurgitation is characterized by a diastolic decrescendo murmur and wide pulse pressure.

Mitral Regurgitation presents as a holosystolic murmur radiating to the axilla.

Valsalva and standing decrease preload, making most murmurs quieter except for MVP and HOCM.

Inspiration selectively increases the intensity of right-sided heart murmurs.

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