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Fixed, split S2
Widened pulse pressure
Systolic murmur that increases with valsalva
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This patient is showing signs and symptoms of heart failure. The history of infective endocarditis paired with the carotid pulse findings raise suspicion for aortic regurgitation and one ought to examine for a widened pulse pressure.The most common cause of aortic regurgitation is a bicuspid aortic valve. Aortic regurgitation following infective endocarditis is a result of post inflammatory scarring. Early symptoms generally include palpitations and dyspnea on exertion. Late symptoms are those indicative of heart failure as well as syncope. On exam, one may detect a widened pulse pressure (a large difference between the systolic and diastolic blood pressure) and involuntary head bobbing.As reviewed by Cheitlin, medical management of aortic regurgitation includes after load-reducing agents such as calcium channel blockers, angiotensin-converting enzyme inhibitors, or hydralazine. These medications have been shown to decrease the progression of cardiac enlargement and even postpone the timing of valve replacement in asymptomatic patients with moderate to severe aortic regurgitation.Oxenham et al., in a non-blinded, randomized controlled trial, compared mechanical valve to bioprosthetic valve for aortic valve replacement. Surgery is the best option for patients with acute aortic regurgitation resulting in left heart failure. Osenham et al. found that mechanical valves were associated with fewer re-operations but more major bleeding over 20 years compared to bioprosthetic valves.Incorrect Answers:Answer 1: A mid-systolic click is most commonly associated with mitral valve prolapse.Answer 2: A fixed, split S2 is not associated with aortic regurgitation but sometimes with a septal defect or pulmonary hypertension.Answer 3: A venous hum is most commonly heard with a patent ductus arteriosus.Answer 5: For testing purposes, Valsalva increases intrathoracic pressure thereby decreasing venous return to the heart, and subsequent blood flow through the chambers, increasing the murmur in hypertrophic cardiomyopathy but decreasing the murmur in aortic regurgitation (as a smaller volume of blood is available to backflow through the valve).
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