A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
An otherwise healthy 25-year-old man comes to the physician because of a 3-month history of intermittent palpitations and worsening shortness of breath on exertion. He has not had chest pain or nocturnal dyspnea. The patient is 195 cm (6 ft 5 in) tall and weighs 70 kg (154 lbs); BMI is 18.4 kg/m2. His pulse is 110/min and blood pressure is 140/60 mm Hg. The lungs are clear to auscultation. Cardiac examination is shown. Which of the following is the most likely diagnosis?
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A
Aortic regurgitationCorrect. Marfanoid habitus with wide pulse pressure (140/60) is classic for aortic regurgitation from aortic root dilation; the murmur is an early decrescendo diastolic murmur.
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B
Tricuspid stenosisIncorrect. Tricuspid stenosis would produce signs of right-heart inflow obstruction (elevated JVP with prominent a wave, hepatomegaly), not a wide pulse pressure.
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C
Aortic stenosisIncorrect. Aortic stenosis produces a NARROW pulse pressure with a slow-rising, late-peaking pulse — opposite of this patient's wide pulse pressure.
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D
Tricuspid regurgitationIncorrect. Tricuspid regurgitation causes right-sided findings (elevated JVP with prominent v wave, pulsatile liver, peripheral edema), not the wide pulse pressure described.
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E
Mitral valve prolapseIncorrect. Mitral valve prolapse is common in Marfanoid patients and produces a mid-systolic click with late systolic murmur, but it does not cause a wide pulse pressure — that finding specifically signals aortic regurgitation.
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Answer: A. A young, tall, thin man (suggestive of Marfan syndrome) with palpitations, dyspnea on exertion, and a wide pulse pressure (140/60 — pulse pressure of 80 mmHg, well above the normal ~40) has classic findings of aortic regurgitation. The peripheral signs of AR all stem from the wide pulse pressure: water-hammer (Corrigan) pulse, head bobbing (de Musset sign), Quincke pulse in the nail beds, Traube sign over the femoral artery, and Duroziez sign on femoral compression.
Marfan syndrome, caused by FBN1 mutations affecting fibrillin-1, predisposes to aortic root dilation, which causes aortic regurgitation when the aortic annulus dilates and the leaflets fail to coapt. The murmur of AR is an early, decrescendo diastolic murmur heard best at the left lower sternal border with the patient leaning forward.
Aortic stenosis causes a NARROW pulse pressure (slow, late-peaking pulse), and is rare in a young man without congenital bicuspid valve. Tricuspid stenosis and tricuspid regurgitation cause right-sided findings (elevated JVP, hepatomegaly, peripheral edema) — not this profile.
**Why each option:**
**A.** Correct. Marfanoid habitus with wide pulse pressure (140/60) is classic for aortic regurgitation from aortic root dilation; the murmur is an early decrescendo diastolic murmur.
**B.** Tricuspid stenosis would produce signs of right-heart inflow obstruction (elevated JVP with prominent a wave, hepatomegaly), not a wide pulse pressure.
**C.** Aortic stenosis produces a NARROW pulse pressure with a slow-rising, late-peaking pulse — opposite of this patient's wide pulse pressure.
**D.** Tricuspid regurgitation causes right-sided findings (elevated JVP with prominent v wave, pulsatile liver, peripheral edema), not the wide pulse pressure described.