A 31-year-old man comes to the physician because of a 5-day history of fever, chills, and dyspnea. His temperature is 38.9°C (102°F) and pulse is 90/min. Cardiac examination shows a murmur. In addition to other measures, cardiac catheterization is performed. A graph showing the results of the catheterization is shown. This patient most likely has which of the following valvular heart defects?
Q2
A 27-year-old woman, who recently immigrated from Bangladesh, presents to her primary care physician to discuss birth control. During a review of her past medical history, she reports that as a child she had a recurrent sore throat and fever followed by swollen and aching hip and knee joints. These symptoms returned every season and were never treated but went away on their own only to return with the next typhoon season. When asked about any current complaints, the patient says that she sometimes has shortness of breath and palpitations that do not last long. A physical exam is performed. In which of the auscultation sites will a murmur most likely be heard in this patient?
Q3
A 62-year-old man comes to the physician for decreased exercise tolerance. Over the past four months, he has noticed progressively worsening shortness of breath while walking his dog. He also becomes short of breath when lying in bed at night. His temperature is 36.4°C (97.5°F), pulse is 82/min, respirations are 19/min, and blood pressure is 155/53 mm Hg. Cardiac examination shows a high-pitch, decrescendo murmur that occurs immediately after S2 and is heard best along the left sternal border. There is an S3 gallop. Carotid pulses are strong. Which of the following is the most likely diagnosis?
Q4
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?
Q5
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?
Q6
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?
Q7
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?
Q8
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?
Q9
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?
Q10
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?
Valvular heart disease US Medical PG Practice Questions and MCQs
Question 1: A 31-year-old man comes to the physician because of a 5-day history of fever, chills, and dyspnea. His temperature is 38.9°C (102°F) and pulse is 90/min. Cardiac examination shows a murmur. In addition to other measures, cardiac catheterization is performed. A graph showing the results of the catheterization is shown. This patient most likely has which of the following valvular heart defects?
A. Mitral regurgitation
B. Aortic regurgitation (Correct Answer)
C. Mitral stenosis
D. Pulmonary regurgitation
E. Aortic stenosis
Explanation: ***Aortic regurgitation***
- Aortic regurgitation is characterized by a high-pitched **diastolic decrescendo murmur**, best heard at the left sternal border.
- The catheterization graph shows a **rapid decline in aortic pressure during diastole**, signifying blood flowing back into the left ventricle, which is characteristic of aortic regurgitation.
*Mitral regurgitation*
- Mitral regurgitation would cause a **pansystolic murmur** and a large **V wave in the pulmonary capillary wedge pressure tracing**, neither of which is implied by the provided information.
- Its primary hemodynamic feature is blood flowing back into the **left atrium during systole**, not diastolic aortic pressure changes.
*Mitral stenosis*
- Mitral stenosis typically presents with a **diastolic rumble** and an **opening snap**, which are different from the findings described.
- Hemodynamically, it would show an **elevated left atrial pressure** and a pressure gradient across the mitral valve during diastole.
*Pulmonary regurgitation*
- Pulmonary regurgitation involves the flow of blood from the pulmonary artery back into the **right ventricle during diastole**.
- This condition would lead to characteristic changes in **right ventricular and pulmonary artery pressures**, not the left-sided heart pressures shown in the graph.
*Aortic stenosis*
- Aortic stenosis causes a **systolic crescendo-decrescendo murmur**, often with radiation to the carotids.
- Hemodynamically, it would show a **significant pressure gradient across the aortic valve during systole** and a delayed carotid upstroke.
Question 2: A 27-year-old woman, who recently immigrated from Bangladesh, presents to her primary care physician to discuss birth control. During a review of her past medical history, she reports that as a child she had a recurrent sore throat and fever followed by swollen and aching hip and knee joints. These symptoms returned every season and were never treated but went away on their own only to return with the next typhoon season. When asked about any current complaints, the patient says that she sometimes has shortness of breath and palpitations that do not last long. A physical exam is performed. In which of the auscultation sites will a murmur most likely be heard in this patient?
A. Point 5 (Correct Answer)
B. Point 4
C. Point 2
D. Point 3
E. Point 1
Explanation: ***Point 5***
- The patient's history of recurrent sore throat, fever, and migratory polyarthritis (swollen and aching hip and knee joints) followed by intermittent shortness of breath and palpitations is highly suggestive of **rheumatic fever** with subsequent **rheumatic heart disease**.
- This condition most commonly affects the **mitral valve**, leading to **mitral stenosis** or regurgitation, which would produce an apical murmur heard best at point 5 (the cardiac apex).
*Point 4*
- Point 4 corresponds to the **tricuspid area** (lower left sternal border). While rheumatic heart disease can affect the tricuspid valve, it is less common than mitral valve involvement and usually occurs in conjunction with severe mitral valve disease.
- An isolated murmur here would suggest tricuspid valve pathology, which is less likely as the primary presentation in rheumatic heart disease.
*Point 2*
- Point 2 is the **pulmonic area** (left upper sternal border, second intercostal space). Murmurs heard here typically indicate pulmonary valve disease or flow murmurs.
- While pulmonary hypertension can be a complication of severe left-sided heart disease, primary pulmonic valve involvement in rheumatic heart disease is rare.
*Point 3*
- Point 3 (Erb's point, third intercostal space, left sternal border) is often used to auscultate for murmurs of **aortic regurgitation** or to hear the splitting of S2.
- While aortic valve involvement can occur in rheumatic heart disease, **mitral valve disease** is significantly more prevalent and typically presents earlier and more severely.
*Point 1*
- Point 1 is the **aortic area** (right upper sternal border, second intercostal space). Murmurs heard here are typically associated with **aortic stenosis** or regurgitation.
- Although the aortic valve can be affected by rheumatic heart disease, the mitral valve is the most commonly involved valve, making an apical murmur (Point 5) more likely for the initial and most prominent finding.
Question 3: A 62-year-old man comes to the physician for decreased exercise tolerance. Over the past four months, he has noticed progressively worsening shortness of breath while walking his dog. He also becomes short of breath when lying in bed at night. His temperature is 36.4°C (97.5°F), pulse is 82/min, respirations are 19/min, and blood pressure is 155/53 mm Hg. Cardiac examination shows a high-pitch, decrescendo murmur that occurs immediately after S2 and is heard best along the left sternal border. There is an S3 gallop. Carotid pulses are strong. Which of the following is the most likely diagnosis?
A. Aortic valve regurgitation (Correct Answer)
B. Tricuspid valve regurgitation
C. Mitral valve prolapse
D. Mitral valve regurgitation
E. Mitral valve stenosis
Explanation: ***Aortic valve regurgitation***
- A **high-pitch, decrescendo murmur immediately after S2** and heard best along the **left sternal border** is characteristic of **aortic regurgitation**.
- Symptoms like **dyspnea on exertion** and **orthopnea**, an **S3 gallop**, and a **wide pulse pressure** (155/53 mmHg) further support heart failure due to chronic aortic regurgitation.
*Tricuspid valve regurgitation*
- This typically presents with a **holosystolic murmur** best heard at the **left lower sternal border** that increases with inspiration.
- Clinical signs often include **jugular venous distension** and **peripheral edema**, not primarily a decrescendo diastolic murmur.
*Mitral valve prolapse*
- Characterized by a **mid-systolic click** followed by a **late systolic murmur**, and symptomatically may be asymptomatic or cause palpitations.
- The described diastolic murmur and symptoms of heart failure do not align with mitral valve prolapse.
*Mitral valve regurgitation*
- Typically presents as a **holosystolic murmur** heard best at the **apex** and often radiating to the axilla.
- While it can cause dyspnea and an S3, the character and timing of the murmur reported (decrescendo, immediately after S2) are inconsistent with mitral regurgitation.
*Mitral valve stenosis*
- This condition presents with a **diastolic rumble** heard best at the **apex** with an opening snap.
- The murmur described is a high-pitch decrescendo murmur, which is distinct from the low-pitched rumble of mitral stenosis.
Question 4: 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?
A. Failure of the ductus arteriosus to close
B. Defect in the atrial septum
C. Fusion of the right and left coronary leaflets
D. Prolapse of the mitral valve
E. Defect in the ventricular septum (Correct Answer)
Explanation: ***Defect in the ventricular septum***
- A **ventricular septal defect (VSD)** causes a holosystolic, harsh murmur, often loudest at the **left lower sternal border**.
- **Clenching the fist forcefully increases systemic vascular resistance (afterload)**, which enhances the left-to-right shunting through a VSD, thereby **increasing the intensity** of the murmur.
*Failure of the ductus arteriosus to close*
- A **patent ductus arteriosus (PDA)** typically presents with a **continuous "machinery-like" murmur**, not one that increases with clenching a fist.
- The murmur of a PDA is usually best heard in the **pulmonary area** (left upper sternal border).
*Defect in the atrial septum*
- An **atrial septal defect (ASD)** usually causes a **systolic ejection murmur** over the pulmonic area due to increased flow across the pulmonary valve, and a **fixed split S2**.
- Its intensity is generally **not significantly altered by acute changes in systemic vascular resistance** like clenching a fist.
*Fusion of the right and left coronary leaflets*
- This description is characteristic of a **bicuspid aortic valve** leading to **aortic stenosis**.
- Aortic stenosis typically causes a **systolic ejection murmur** that **decreases** in intensity with maneuvers that increase afterload (like clenching a fist) due to reduced stroke volume.
*Prolapse of the mitral valve*
- **Mitral valve prolapse (MVP)** is characterized by a **mid-systolic click** followed by a **late-systolic murmur**.
- **Increasing afterload** (clenching a fist) would typically **delay the click and shorten the murmur**, or make it softer, as it *reduces* the degree of prolapse.
Question 5: 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?
A. High-frequency, diastolic murmur heard best at the 2nd left intercostal space
B. Harsh, late systolic murmur that radiates to the carotids
C. Blowing, early diastolic murmur heard best at the Erb point
D. High-pitched, holosystolic murmur that radiates to the axilla (Correct Answer)
E. Rumbling, delayed diastolic murmur heard best at the cardiac apex
Explanation: ***High-pitched, holosystolic murmur that radiates to the axilla***
- The patient's symptoms of **fatigue**, **dyspnea on exertion** and **orthopnea**, combined with a heart murmur, are highly suggestive of **heart failure** caused by **mitral regurgitation**.
- A **high-pitched**, **holosystolic murmur** heard best at the **apex** and **radiating to the axilla** is the classic description of mitral regurgitation.
*High-frequency, diastolic murmur heard best at the 2nd left intercostal space*
- This describes the murmur of **pulmonary regurgitation**, which is typically heard best at the **left upper sternal border**.
- The patient's symptoms are more consistent with left-sided heart failure due to a different valvular issue.
*Harsh, late systolic murmur that radiates to the carotids*
- This is the characteristic murmur of **aortic stenosis**, which is heard best at the **right upper sternal border**.
- While aortic stenosis can cause similar symptoms, the description of the murmur and the specific context of heart failure symptoms here point away from it.
*Blowing, early diastolic murmur heard best at the Erb point*
- This describes the **diastolic murmur of aortic regurgitation**, often heard best at the **Erb's point** (3rd intercostal space, left sternal border).
- While aortic regurgitation can cause heart failure, its murmur is diastolic, not holosystolic, and the maximal intensity and radiation differ from the classic mitral regurgitation.
*Rumbling, delayed diastolic murmur heard best at the cardiac apex*
- This is the characteristic murmur of **mitral stenosis**, which is typically preceded by an **opening snap**.
- Mitral stenosis would lead to different hemodynamic changes and often presents with symptoms related to pulmonary congestion, but the murmur timing and quality are distinct from a holosystolic murmur of regurgitation.
Question 6: 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?
A. Left atrial mass arising from the region of the septal fossa ovalis
B. Doming of the mitral valve leaflets in diastole
C. Prolapse of a mitral valve leaflet of ≥2 mm above the level of the annulus in systole (Correct Answer)
D. Retrograde blood flow into the right atrium
E. High pressure gradient across the aortic valve
Explanation: ***Prolapse of a mitral valve leaflet of ≥2 mm above the level of the annulus in systole***
- The clinical presentation with a **midsystolic click** followed by a **late-systolic high-pitched murmur over the cardiac apex** is characteristic of **mitral valve prolapse (MVP)**.
- The changes in the click and murmur timing and intensity with **standing (earlier, louder)** and **squatting (later, softer)** are classic findings, reflecting changes in left ventricular volume that affect the onset of valve prolapse.
*Left atrial mass arising from the region of the septal fossa ovalis*
- This description is highly suggestive of a **myxoma**, typically found in the left atrium, which can cause symptoms of **obstructive heart failure** or **embolism**.
- A myxoma would not typically present with the characteristic **midsystolic click** and **late-systolic murmur** that changes with position.
*Doming of the mitral valve leaflets in diastole*
- **Doming of the mitral valve leaflets in diastole** is characteristic of **mitral stenosis**, where the valve fails to open properly.
- Mitral stenosis would present with a **diastolic murmur**, not a midsystolic click and late-systolic murmur.
*Retrograde blood flow into the right atrium*
- **Retrograde blood flow into the right atrium** indicates **tricuspid regurgitation**, which would typically manifest as a **holosystolic murmur** best heard at the lower left sternal border, often with prominent jugular venous pulsations.
- This finding is inconsistent with the patient's auscultatory findings at the cardiac apex.
*High pressure gradient across the aortic valve*
- A **high pressure gradient across the aortic valve** signifies **aortic stenosis**, which is characterized by a **systolic ejection murmur** best heard at the right upper sternal border with radiation to the carotids.
- This condition would not produce a midsystolic click or a late-systolic murmur at the apex.
Question 7: 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?
A. Connective tissue disease
B. Congenital bicuspid aortic valve (Correct Answer)
C. Syphilis
D. Rheumatic heart disease
E. Myxomatous degeneration
Explanation: ***Congenital bicuspid aortic valve***
- The patient's age (32 years old), progressive symptoms of **aortic regurgitation** (decreasing exercise tolerance, shortness of breath, early diastolic decrescendo murmur), and location of the murmur are highly suggestive of a **bicuspid aortic valve**.
- This is the **most common congenital heart defect**, affecting 1-2% of the population, and is the leading cause of **aortic stenosis** and **aortic insufficiency** in younger adults in developed countries.
*Connective tissue disease*
- While connective tissue diseases such as **Marfan syndrome** or **Ehlers-Danlos syndrome** can cause aortic root dilation and regurgitation, they are less common than a bicuspid aortic valve as a primary cause of isolated aortic regurgitation in this age group.
- These conditions typically present with other systemic features (e.g., arachnodactyly, skin hyperextensibility) that are not mentioned in the patient's history.
*Syphilis*
- **Syphilitic aortitis** can cause aortic root dilation and aortic regurgitation, typically as a late-stage manifestation of **tertiary syphilis**.
- While possible, it is less common in developed countries today due to effective antibiotic treatment, and the patient's asymptomatic progression over 5 years might suggest a congenital rather than an infectious cause in this context.
*Rheumatic heart disease*
- **Rheumatic fever** is a common cause of valvular heart disease globally, but its incidence has significantly declined in developed countries due to improved hygiene and antibiotic use for **streptococcal infections**.
- While it can affect the aortic valve, it more commonly affects the **mitral valve** and usually presents with symptoms earlier in life or with a history of recurrent fevers.
*Myxomatous degeneration*
- **Myxomatous degeneration** primarily affects the **mitral valve**, leading to **mitral valve prolapse** and regurgitation.
- While it can sometimes affect the aortic valve, it is a less common cause of isolated aortic regurgitation and often presents with different clinical features or imaging findings.
Question 8: 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?
A. Radiation of murmur to the axilla (Correct Answer)
B. Results in mixing of blood between left and right ventricles
C. Radiation of murmur to the right sternal border
D. Presents with an opening snap
E. Radiation of murmur to the neck
Explanation: ***Radiation of murmur to the axilla***
- The patient's presentation of a **systolic murmur** best heard at the **5th intercostal space at the left mid-clavicular line** (the apex) strongly suggests **mitral regurgitation**.
- A characteristic feature of **mitral regurgitation** is the **radiation of the murmur to the axilla**.
*Results in mixing of blood between left and right ventricles*
- This describes a **ventricular septal defect (VSD)**, which presents with a holosystolic murmur typically loudest at the **left sternal border** and not the apex.
- While VSD is a systolic murmur, its location and consequence of intracardiac shunting differ from the described clinical picture.
*Radiation of murmur to the right sternal border*
- This type of radiation is commonly associated with benign flow murmurs or sometimes **tricuspid regurgitation**, though tricuspid regurgitation is typically heard loudest at the **lower left sternal border** and increases with inspiration.
- It is not characteristic of a murmur heard best at the apex with the described qualities.
*Presents with an opening snap*
- An **opening snap** is a characteristic finding of **mitral stenosis**, which is a **diastolic murmur**, not a systolic murmur as described in the patient.
- The murmur in this patient is heard throughout systole, ruling out mitral stenosis.
*Radiation of murmur to the neck*
- Radiation to the neck is a classic feature of **aortic stenosis**, which is typically a **systolic ejection murmur** heard best at the **right upper sternal border**, radiating to the carotid arteries.
- This differs significantly from a murmur heard maximally at the apex.
Question 9: 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?
A. Continuous murmur inferior to the left clavicle
B. Holosystolic murmur at the apex radiating to the axilla
C. Crescendo-decrescendo systolic murmur radiating to carotids
D. Late systolic murmur with a midsystolic click
E. Holosystolic murmur at the lower left sternal border (Correct Answer)
Explanation: ***Holosystolic murmur at the lower left sternal border***
- This presentation is classic for a **ventricular septal defect (VSD)**, which is the most common congenital heart defect. The murmur is **holosystolic** and best heard at the **lower left sternal border**.
- The key physiological findings support VSD: the murmur **decreases with Valsalva** (decreased venous return → decreased left-to-right shunt) and **increases with handgrip and squatting** (increased systemic vascular resistance → increased left-to-right shunt across the defect).
- **Exertional dyspnea** in a previously healthy child can occur with moderate-sized VSDs due to increased pulmonary blood flow. Small VSDs may be asymptomatic until increased activity demands reveal the limitation.
*Continuous murmur inferior to the left clavicle*
- This describes a **patent ductus arteriosus (PDA)**, which produces a continuous **"machinery-like" murmur** heard best in the infraclavicular area and under the left clavicle.
- While PDA can cause exertional symptoms, the murmur characteristics don't match the holosystolic pattern described, and the dynamic maneuver responses differ from this case.
*Holosystolic murmur at the apex radiating to the axilla*
- This is the classic presentation of **mitral regurgitation**. The murmur would **increase with squatting** (increased preload), but the location (apex radiating to axilla) doesn't match the lower left sternal border location described.
- Mitral regurgitation is uncommon in otherwise healthy children without rheumatic disease or structural abnormalities.
*Crescendo-decrescendo systolic murmur radiating to carotids*
- This describes **aortic stenosis**, which produces an **ejection systolic murmur** that radiates to the carotids.
- Aortic stenosis has a crescendo-decrescendo (ejection) pattern, not holosystolic, and the location and radiation pattern don't match this patient's findings.
*Late systolic murmur with a midsystolic click*
- This is pathognomonic for **mitral valve prolapse (MVP)**. In MVP, the click and murmur **move earlier and become louder with Valsalva** (decreased ventricular volume allows earlier prolapse), which is opposite to this patient's findings.
- MVP is the opposite response: louder with Valsalva, softer with squatting.
Question 10: 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. A holosystolic murmur at the 4th intercostal midclavicular line
B. A water-hammer pulse when palpating the radial artery (Correct Answer)
C. Decreased blood pressure as measured in the lower extremities compared to the upper extremities
D. A harsh crescendo-decrescendo systolic murmur in the right second intercostal space
E. A consistent gallop with an S4 component
Explanation: ***A water-hammer pulse when palpating the radial artery***
- The patient's history of **opiate overdose**, fever, chills, and the presence of **Janeway lesions** (Figures A and B) on the hands strongly suggest **infective endocarditis**. The head bobbing (Musset's sign) indicates **severe aortic regurgitation**.
- **Water-hammer pulse** (Corrigan's pulse) is a classic sign of **severe aortic regurgitation**, characterized by a rapid, forceful arterial pulse that quickly collapses due to a large stroke volume and rapid diastolic runoff.
*A holosystolic murmur at the 4th intercostal midclavicular line*
- A holosystolic murmur at the 4th intercostal midclavicular line is typically associated with **mitral regurgitation**, which is less likely given the prominent signs of aortic regurgitation.
- While endocarditis can affect the mitral valve, the specific clinical signs point towards **aortic valve involvement**.
*Decreased blood pressure as measured in the lower extremities compared to the upper extremities*
- This finding is characteristic of **coarctation of the aorta**, a congenital heart defect, which is not suggested by the patient's presentation or risk factors.
- The patient's symptoms are more consistent with an acute infectious process affecting the heart valves.
*A harsh crescendo-decrescendo systolic murmur in the right second intercostal space*
- A harsh crescendo-decrescendo systolic murmur in the right second intercostal space is typical of **aortic stenosis**.
- While aortic insufficiency is present, the murmur for uncomplicated aortic insufficiency is usually a **diastolic decrescendo murmur**, not a harsh systolic murmur.
*A consistent gallop with an S4 component*
- An S4 gallop is typically heard in conditions involving **decreased ventricular compliance** (e.g., severe hypertension, aortic stenosis, hypertrophic cardiomyopathy).
- While endocarditis can cause heart failure, an S4 gallop is not a direct or primary sign of **aortic regurgitation**. An S3 gallop is more commonly associated with **volume overload** and heart failure, which might develop in severe aortic regurgitation.
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