A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 62-year-old woman comes to the physician because of a 2-month history of exertional shortness of breath and fatigue. She sometimes wakes up at night coughing and gasping for air. Cardiac examination shows a grade 3/6 holosystolic murmur best heard at the apex. Which of the following physical exam findings would be consistent with an exacerbation of this patient's condition?
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A
Early diastolic extra heart soundCorrect. An S3 gallop is an early diastolic extra heart sound that signals volume overload and decompensated systolic heart failure — expected in worsening chronic mitral regurgitation.
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B
Prominent V waveIncorrect. Prominent V wave on the JVP signifies tricuspid regurgitation (regurgitant flow during ventricular systole), not mitral regurgitation, which is heard at the apex.
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C
Head bobbingIncorrect. Head bobbing (de Musset sign) reflects the wide pulse pressure of severe chronic aortic regurgitation, not mitral disease.
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D
Absence of A2 heart soundIncorrect. Absence of A2 occurs in severe aortic stenosis when the calcified valve cannot close audibly — unrelated to mitral pathology.
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E
Fixed splitting of S2Incorrect. Fixed splitting of S2 is the hallmark of an atrial septal defect (constant right-sided volume overload); it is unrelated to decompensated mitral regurgitation, whose marker of worsening LV dysfunction is an S3 gallop.
↑ Tap an answer to reveal the reasoning
Answer: A. A holosystolic murmur best heard at the apex in an older woman with exertional dyspnea, fatigue, and paroxysmal nocturnal dyspnea (waking at night gasping for air) describes chronic mitral regurgitation with progression toward heart failure. As MR worsens, the regurgitant volume increases LV preload; the LV dilates and eventually develops systolic dysfunction. Pulmonary venous pressures rise, producing the orthopnea/PND.
An S3 gallop is an early diastolic extra heart sound produced by rapid passive filling of a dilated, volume-overloaded ventricle. It is the hallmark auscultatory finding of decompensated systolic heart failure and significant chronic mitral regurgitation. Detection of an S3 in this patient is consistent with exacerbation/decompensation of her MR.
Prominent V wave on JVP is seen in tricuspid regurgitation (giant V waves) and reflects right atrial filling against an incompetent tricuspid valve. Head bobbing (de Musset sign) is a peripheral marker of severe chronic aortic regurgitation with wide pulse pressure. Absence of A2 indicates severe aortic stenosis with immobile/calcified leaflets unable to produce an audible closing sound — not mitral pathology.
**Why each option:**
**A.** Correct. An S3 gallop is an early diastolic extra heart sound that signals volume overload and decompensated systolic heart failure — expected in worsening chronic mitral regurgitation.
**B.** Prominent V wave on the JVP signifies tricuspid regurgitation (regurgitant flow during ventricular systole), not mitral regurgitation, which is heard at the apex.
**C.** Head bobbing (de Musset sign) reflects the wide pulse pressure of severe chronic aortic regurgitation, not mitral disease.
**D.** Absence of A2 occurs in severe aortic stenosis when the calcified valve cannot close audibly — unrelated to mitral pathology.