Question

Question #36 of 50 ^ FLAG QUESTION During a high school pre-participation physical evaluation event, you encounter the following individual. Make the best clinical assessment. White female age 15; friendly and outgoing; appears completely healthy, WDWN Denies any sports injury, prior surgeries or illnesses History - summary Occasionally experiences palpitations and pressure in her chest during and after exercise. Out of breath earlier during exercise compared to her friends. Drugs: has experimented with cocaine and marijuana. No medical drugs. Family history: father and maternal grandmother died before age 60 due to heart failure due to atrial myxoma and thoracic aortic dissection respectively. Physical Examination - summary BP R and L. arms: 115/55 mmHg: HR: 50; RR: 12; Temp: 98.9°F Ht: 5'6" Weight: 124 Ib BMT: 20 Appearance: normal chest configuration, arm span 50% Special tests: negative thumb sign and negative wrist sign EENT: normal palate height, B/L myopia, visual acuity 20/20 with contact lenses Lungs: vesicular breath sounds, discrete bibasilar crackles with patient seated Cardiovascular: bounding amplitude B/. carotids (Corrigan (ak a waterhammer] pulse), pulsus bisferons, Quinke pulse, de Musset sign. Traube sign; equal pulse amplitude, 3/4, BL upper and lower extremities Apical impulse: PMI at the L. 6th ICs in the Lanterior axillary line, bounding, size 3 cm, thrills, sustained duration Heart: high-pitched, blowing, diastolic decrescendo murmur grade 46 PMI at the 2nd RICS parasternally; murmur radiation from the 2nd RICS via Ert's point toward the apex. No radiation along the carotids or to the L axilla or back Dynamic auscultation: Squatting => increased murmur intensity Seated leaning forward in suspended exhalation => increased murmur intensity Valsalva and standing up -> decreased murmur intensity. Given the clinical data, what is the best assessment of this patient?

Answer 1

This patient is having Aortic regurgitation because above signs like water hammer pulse , demussets sign, quinckes sign , traube sign, duroziezs sign and many other signs like light house sign , Gerhardt's sign pistol shot femorals these all the specific signs for aortic regurgitation

The murmer of aortic regurgitation is early diaatodia murmur high pitched, decrescendo best heard at erbs area or neo aortic area.The patient of aortic regurgitation also have Corrigan's pulse i.e jerky carotid pulse characterized by full expansion followed by quick collapse . Hills sign is present i.e popliteal cuff systolic pressure exceeding brachial cuff systolic pressure by more than 20mmHg

A difference of 20-39mmHg indicates mild AR

A difference of 40-59mmHg indicates moderate AR

A difference of 60mmHg or more indicates severe AR

While in ventricular septal defect Harsh systolic murmer best heard at the third or fourth intercostal space radiating all over precordium history of recurrent respi infections are present hyperdynamic precordium apex beat is shifted down and out which is absent in history in this case

While in case of Marfan's Syndrome

Patient may experience:

Pain areas: in the back

Heart: mitral valve prolapse or murmur

Mouth: abnormally raised roof of the mouth or crowded teeth

Visual: blurred vision or nearsightedness

Chest: bulging chest or sunken chest

Also common: abnormally long fingers, collapsed lung, disproportionately long arms and legs, double jointed, fatigue, flat feet, scoliosis, small pupils, stretch marks, or tall and slender build . These all features are absent in this case

While in case of mitral regurgitation high volume that may become collapsing pulse is present. JVP is normal in uncomplicated MR, on inspection rocking motion of precordium is seen, apex beat shifted downwards and laterally, and is hyperdynamic in character, on auscultation first heart sound is soft, in severe MR S2 is widely split due to aortic valve closure occurring early, murmur of MR is high pitched, blowing , and usually pansystolic best heard at apex commonly radiating to axilla and left interscapular region. Mid diastolic flow murmer at apex are present in severe cases in this patient these all things are not seen so MR is not the diagnosis