A 65 year old male who is known to
have valvular heart disease and chronic heart failure is admitted to the ward
for treatment of cellulitis of his right leg. The patient is on digoxin,
diuretics and warfarin.
On examination of the patient you note
that his pulse rate is 80 beats per minute irregular , not collapsing , BP
130/80, JVP elevated with a prominent V wave , apex displaced the 6th
left intercostal space anterior axillary line , thrusting in nature , there
was left parasternal heave , first heart sound was soft , there was a blowing
pan systolic murmur at the apex and this radiated to the axilla, there was
another pan systolic murmur at the left sternal edge which increased with
inspiration and there was an early blowing decrescendo early diastolic murmur
at the left sternal edge.
In this patient which of the following
physical signs would enable you to determine the valvular origin of the
blowing decrescendo early diastolic murmur at the left sternal edge?
Thrusting apex beat
Soft first heart sound
Pulse not collapsing