USMLE Step 2 - Question 37

A 35 year old female with a history of HIV presents with increasing dyspnea on exertion. Her temperature is 37.0, blood pressure 120/80, heart rate 110, respirations 20, and oxygen saturation 95% on room air. Physical examination reveals normal breath sounds, elevated jugular venous pressure with large V waves, a III/VI holosystolic murmur at the right lower sternal border which becomes louder with inspiration, a pulsatile liver, and 2+ lower extremity edema. Her chest x-ray is below. Which of the following is most likely contributing to her dyspnea?

Case4-1

A. Tricuspid valve regurgitation

B. Tricuspid valve stenosis

C. Mitral valve regurgitation

D. Mitral valve stenosis

This patient has pulmonary hypertension most likely related to her HIV disease. Her chest x-ray reveals enlarged pulmonary arteries and right-sided heart chambers. The murmur described in the question is that of tricuspid regurgitation. Remember that there are only 3 holosystolic murmurs: mitral regurgitation, tricuspid regurgitation, and a ventricular septal defect. Tricuspid regurgitation gets louder with inspiration (Carvallo’s sign) due to increased venous return to the right heart. Besides the murmur, other physical exam findings include large V waves in the jugular venous pulsations (from blood ejecting backwards from the right ventricle directly into the jugular veins), a pulsatile liver again from backward flow, and lower extremity edema. Treatment of tricuspid regurgitation includes reversing the primary cause. Rarely if there is an organic problem with the tricuspid valve (such as endocarditis or carcinoid syndrome) causing regurgitation, tricuspid valve replacement can be done.