A 20-year-old woman comes to the office for a routine employment physical examination. She reports no symptoms, and her medical history includes no significant conditions. The patient has good exercise tolerance and does not take any medications or use illicit drugs. Her blood pressure is 125/65 mm Hg and pulse is 80/min. Cardiac auscultation reveals an early diastolic murmur at the left sternal border that is best heard with expiration. Carotid pulses are normal bilaterally, and there are no bruits. ECG shows normal sinus rhythm without any significant abnormalities. What is the best next step in management of this patient?

Question

A 20-year-old woman comes to the office for a routine employment physical examination.  She reports no symptoms, and her medical history includes no significant conditions.  The patient has good exercise tolerance and does not take any medications or use illicit drugs.  Her blood pressure is 125/65 mm Hg and pulse is 80/min.  Cardiac auscultation reveals an early diastolic murmur at the left sternal border that is best heard with expiration.  Carotid pulses are normal bilaterally, and there are no bruits.  ECG shows normal sinus rhythm without any significant abnormalities.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Diastolic and continuous murmurs are usually due to an underlying pathologic cause. Their presence should prompt further evaluation with a transthoracic echocardiogram, which can identify valvular regurgitation and evaluate for any associated structural abnormalities or hemodynamic consequences. Aortic regurgitation leads to an early and gradually decreasing (decrescendo) diastolic murmur that begins immediately after A2 (aortic component of the second heart sound). The murmur is high-pitched, has a blowing quality, and, when it is due to valvular (rather than aortic root) abnormalities, is best heard along the left sternal border at the third and fourth intercostal spaces with the patient sitting up and leaning forward while holding the breath in full expiration. (Choice A) Chest radiography in patients with chronic aortic regurgitation can reveal dilation of the ascending aorta or cardiomegaly. These findings are nonspecific and are not useful in the diagnosis. (Choices B and D) Exercise ECG is a useful screening test in patients with an intermediate probability of coronary heart disease. Coronary CT angiography is a noninvasive method to assess coronary artery calcification and intraluminal stenosis in patients with suspected coronary heart disease. These studies are not indicated in the initial evaluation of the murmur of aortic regurgitation. (Choice E) A midsystolic murmur can be detected occasionally in young, asymptomatic adults. This murmur is usually benign and, in the absence of symptoms or other abnormal findings, does not require further evaluation. Educational objective: Diastolic and continuous murmurs are usually due to an underlying pathologic cause, and their presence should prompt further evaluation with a transthoracic echocardiogram. Midsystolic murmurs in otherwise young, asymptomatic adults are usually benign and do not require further evaluation.

A 20-Year-Old Woman Comes to the Office for a Routine