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Zorluk: ZorPhysical Examination Findings

A female patient, aged 61, presents to her primary care physician reporting a progressive decline in her exercise tolerance over the past three months. She notes shortness of breath after climbing a single flight of stairs, alongside generalized fatigue. Her past medical history is significant for a severe febrile illness accompanied by migratory joint pains during adolescence. Current vital signs include a blood pressure of 158/52 mmHg and a regular pulse of 92/min. Careful inspection of the hands reveals alternating blanching and flushing of the nail beds when gentle pressure is applied to the tip of the nails. Auscultation over the femoral arteries detects a to-and-fro bruit with both systolic and diastolic components upon partial compression. Which of the following additional physical examination findings is most likely to be present in this patient?

  1. A low-pitched, mid-to-late diastolic rumble heard at the cardiac apex without an opening snapCevap
  2. B
    An early diastolic sound followed by a low-pitched rumbling murmur with presystolic accentuation
  3. C
    A delayed and diminished amplitude of the carotid pulse upstroke during palpation
  4. D
    A harsh crescendo-decrescendo systolic murmur that increases in intensity during the strain phase of the Valsalva maneuver
  5. E
    An inspiratory decrease in systolic blood pressure greater than 10 mmHg

Cevap

A low-pitched, mid-to-late diastolic rumble heard at the cardiac apex without an opening snap
The correct answer accurately describes the Austin Flint murmur. The patient's presentation—including a widened pulse pressure, Quincke's pulse (capillary pulsations), and Duroziez's sign (systolic and diastolic femoral bruit)—is highly specific for severe aortic regurgitation. In severe cases, the regurgitant jet of blood from the aorta flows backward into the left ventricle and strikes the anterior leaflet of the mitral valve. This causes the mitral leaflet to partially close prematurely during diastole, creating a functional mitral stenosis. Clinically, this manifests as a soft, low-pitched, mid-to-late diastolic rumble heard best at the cardiac apex. Notably, because there is no true structural fusion of the mitral commissures, this murmur lacks the opening snap that characterizes rheumatic mitral stenosis.

Adım Adım Çözüm

1
Analyze the vital signs and peripheral physical examination findings.
The patient has a wide pulse pressure (158/52 mmHg), Quincke's pulse (capillary pulsations), and Duroziez's sign (femoral to-and-fro bruit).
Identifying the hemodynamic significance of these eponymic signs points toward the primary cardiovascular pathology.
2
Synthesize the findings to establish the most likely primary diagnosis.
The constellation of findings indicates severe aortic regurgitation, likely secondary to previous rheumatic heart disease given her childhood history.
Bounding peripheral pulses, a widened pulse pressure, and these specific peripheral signs are hallmarks of the massive stroke volume and rapid diastolic runoff characterizing severe aortic regurgitation.
3
Identify expected secondary cardiac auscultation findings associated with this specific valvular lesion.
The correct physical examination finding must be a direct consequence of severe aortic regurgitation, such as the Austin Flint murmur.
The regurgitant jet from the incompetent aortic valve impinges on the anterior mitral leaflet, causing a functional mitral stenosis.

Anahtar Kavram

The identification of severe aortic regurgitation through peripheral physical exam signs and the recognition of its associated Austin Flint murmur.
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Physical Examination Findings

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