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Answer: A, Aortic regurgitation
Educational Objective: Diagnose severe aortic
Critique: This patient has aortic
regurgitation. The murmur of aortic regurgitation, described as a
diastolic decrescendo murmur, is heard best at the third left
intercostal space and may be better heard when the patient is at
end-expiration, leaning forward. Chronic aortic regurgitation has
many associated findings, including widened pulse pressure,
bounding carotid and peripheral pulses, and a diffuse and laterally
displaced point of maximal impulse. A low-pitched rumbling
diastolic murmur ("Austin Flint murmur") can accompany aortic
regurgitation and is caused by premature closure of the mitral
leaflets due to the regurgitant aortic flow.
The auscultatory findings for mitral stenosis include an opening
snap with a low-pitched mid-diastolic murmur (often described as a
rumble) that accentuates presystole and is heard best at the apex
with the patient in the left lateral decubitus position. It most
often occurs in patients with rheumatic valve disease and is
frequently associated with atrial fibrillation.
A small patent ductus arteriosus in the adult produces an
arteriovenous fistula with a continuous murmur that envelops the
S2 and is characteristically heard beneath the left
clavicle. Patients with a moderate-sized patent ductus arteriosus
may present with a continuous "machinery-type" murmur best heard at
the left infraclavicular area and bounding pulses with a wide pulse
The sinuses of Valsalva are three aortic dilatations just above
the aortic valve cusps. Two of the three sinuses are the origins of
the coronary arteries. Regurgitant blood flow into the sinus
structures fills the coronary arteries and assists in the closure
of the aortic valve cusps. Sinus of Valsalva aneurysm is a type of
aortic root aneurysm. Rupture of the aneurysm will allow flow
between the sinus of Valsalva and either the right atrium or right
ventricle, producing a continuous systolic and diastolic murmur
heard loudest at the second left intercostal space. Clinical
presentation can vary, ranging from asymptomatic to decompensated
heart failure. Ruptured sinus of Valsalva aneurysm more frequently
involves the left or right coronary cusps and less frequently the
Key Point: The murmur of aortic regurgitation
is a diastolic decrescendo murmur heard best at the left third
intercostal space; associated findings include widened pulse
pressure, bounding carotid and peripheral pulses, and a diffuse and
laterally displaced point of maximal impulse.
Choudhry NK, Etchells EE. The rational clinical examination.
Does this patient have aortic regurgitation? JAMA.
1999;281(23):2231-8. [PMID: 10376577]
January International Newsletter