Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

MKSAP: A 70-year-old man with a history of a systolic murmur presents with exertional dyspnea

mksap
Conditions
October 16, 2010
Share
Tweet
Share

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

mksap 15A 70-year-old man with a history of a systolic murmur presents for further assessment of exertional dyspnea. He has had dyspnea his entire life, but has noted a recent deterioration in his exercise capacity. He has no other medical conditions and is on no medications.

On physical examination, his blood pressure is 120/70 mm Hg and pulse is 75/min and regular. The jugular venous pulse contour demonstrates a prominent a wave and the carotid pulses are normal. On cardiac examination, there is a parasternal impulse and a systolic thrill. The apical impulse is not displaced. An ejection click in close proximity to the S1 is heard along the left sternal border and second left intercostal space, which decreases in intensity with inspiration. A grade 4/6 early systolic murmur that increases with inspiration is best heard in the second left intercostal space without radiation to the carotid arteries. No diastolic murmur is noted.

mksap_lg

The electrocardiogram is shown. Chest radiograph demonstrates dilatation of the main pulmonary artery.

Which of the following is the most likely diagnosis in this patient?

A) Aortic valve stenosis
B) Atrial septal defect
C) Mitral valve regurgitation
D) Pulmonary valve stenosis
E) Tricuspid valve regurgitation

Answer and critique

The correct answer is D) Pulmonary valve stenosis.

The patient has characteristic physical examination findings, electrocardiogram, and chest radiograph consistent with pulmonary valve stenosis. The jugular venous pulse contour demonstrates a prominent a wave. A right ventricular lift and systolic thrill are present. An ejection click is noted and is close to the S1, suggesting severe pulmonary valve stenosis. This sound decreases in intensity during inspiration (the only right-sided sound that decreases during inspiration). An early systolic murmur is noted over the pulmonary area. The electrocardiogram demonstrates right ventricular hypertrophy and right axis deviation. The chest radiograph demonstrates pulmonary artery dilatation. The diagnosis can be confirmed by echocardiography.

A bicuspid aortic valve is a more common cause of an ejection click than is congenital pulmonary valve disease, and it is associated with the development of aortic stenosis. The classic symptoms of aortic stenosis include dyspnea, angina, and exertional syncope. Aortic stenosis is characterized by small and late carotid pulsations, a late-peaking systolic murmur loudest in the second right intercostal space, absent splitting of S2, and a sustained apical impulse. The murmur characteristically radiates to one or both carotid arteries. Findings suggesting right ventricular hypertrophy would not be expected on physical examination or on the electrocardiogram.

The characteristic physical examination finding in atrial septal defect is fixed splitting of the a and v waves may be noted on jugular venous assessment. A right ventricular impulse is present. An ejection click may be audible if the pulmonary artery is enlarged but is less common than in patients with pulmonary stenosis. A pulmonary midsystolic murmur and a tricuspid diastolic flow rumble may be heard owing to increased flow through the valves from the left-to-right shunt. A systolic thrill, loud systolic murmur, and post-stenotic dilation of the pulmonary artery would not be expected in a patient with an isolated atrial septal defect.

Chronic mitral valve regurgitation is characterized by a holosystolic murmur at the apex that radiates to the axilla without respiratory variation. Mitral valve regurgitation may cause secondary pulmonary hypertension, but an ejection click and a loud early systolic murmur would not be expected with mitral valve regurgitation, even in the presence of pulmonary hypertension.

Tricuspid valve regurgitation causes a holosystolic murmur noted at the left sternal border. This characteristically increases with inspiration, but marked right ventricular hypertrophy and right axis deviation would not be expected on the electrocardiogram with this valvular lesion. The jugular venous pulse contour demonstrates a prominent v wave with tricuspid regurgitation, rather than a prominent a wave.

Key point

* Characteristic features of pulmonary valve stenosis include a prominent a wave in the jugular venous pulse contour, a parasternal impulse, an ejection click, a systolic thrill, and an early systolic murmur that increases with inspiration.

ADVERTISEMENT

Learn more about ACP’s MKSAP 15.

This content is excerpted from MKSAP 15 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 15 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

Prev

Searching for solace while balancing the care of patient

October 16, 2010 Kevin 0
…
Next

How a tyranny of health is bad for both patients and physicians

October 16, 2010 Kevin 21
…

Tagged as: Patients, Specialist

Post navigation

< Previous Post
Searching for solace while balancing the care of patient
Next Post >
How a tyranny of health is bad for both patients and physicians

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

More by mksap

  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 26-year-old man with back pain

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 36-year-old man with abdominal cramping, diarrhea, malaise, and nausea

    mksap
  • a desk with keyboard and ipad with the kevinmd logo

    MKSAP: 52-year-old woman with osteoarthritis of the right hip

    mksap

More in Conditions

  • Finding healing in narrative medicine: When words replace silence

    Michele Luckenbaugh
  • Why coaching is not a substitute for psychotherapy

    Maire Daugharty, MD
  • Why doctors stay silent about preventable harm

    Jenny Shields, PhD
  • Why gambling addiction is America’s next health crisis

    Safina Adatia, MD
  • How robotics are reshaping the future of vascular procedures

    David Fischel
  • How the shingles vaccine could help prevent dementia

    Marc Arginteanu, MD
  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

ADVERTISEMENT

  • Most Popular

  • Past Week

    • 2 hours to decide my future: How the SOAP residency match traps future doctors

      Nicolette V. S. Sewall, MD, MPH | Education
    • Why removing fluoride from water is a public health disaster

      Steven J. Katz, DDS | Conditions
    • When did we start treating our lives like trauma?

      Maureen Gibbons, MD | Physician
    • In a fractured world, Brian Wilson’s message still heals

      Arthur Lazarus, MD, MBA | Physician
    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • How doctors took back control from hospital executives

      Gene Uzawa Dorio, MD | Physician
  • Past 6 Months

    • Why tracking cognitive load could save doctors and patients

      Hiba Fatima Hamid | Education
    • What the world must learn from the life and death of Hind Rajab

      Saba Qaiser, RN | Conditions
    • The silent toll of ICE raids on U.S. patient care

      Carlin Lockwood | Policy
    • Why shared decision-making in medicine often fails

      M. Bennet Broner, PhD | Conditions
    • My journey from misdiagnosis to living fully with APBD

      Jeff Cooper | Conditions
    • Why we fear being forgotten more than death itself

      Patrick Hudson, MD | Physician
  • Recent Posts

    • When your dream job becomes a nightmare [PODCAST]

      The Podcast by KevinMD | Podcast
    • Finding healing in narrative medicine: When words replace silence

      Michele Luckenbaugh | Conditions
    • Why coaching is not a substitute for psychotherapy

      Maire Daugharty, MD | Conditions
    • When the white coats become gatekeepers: How a quiet cartel strangles America’s health

      Anonymous | Physician
    • Why doctors stay silent about preventable harm

      Jenny Shields, PhD | Conditions
    • Why interoperability is key to achieving the quintuple aim in health care

      Steven Lane, MD | Tech

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...