Rosh Internal Medicine Boost Practice Exam

What is the most likely diagnosis for a patient with a harsh midsystolic ejection murmur and shortness of breath during exertion?

1. Aortic regurgitation

2. Aortic stenosis

3. Mitral regurgitation

4. Tricuspid stenosis

The correct answer is: Aortic stenosis

A harsh midsystolic ejection murmur, particularly when accompanied by shortness of breath during exertion, is highly indicative of aortic stenosis. In this condition, there is an obstruction to blood flow from the left ventricle into the aorta due to narrowing of the aortic valve opening. As the blood is forced through this narrowed space, it creates a characteristic sound described as a harsh or "crescendo-decrescendo" murmur, prominent between the first and second heart sounds. Shortness of breath during physical activity is a common symptom in aortic stenosis because the heart struggles to maintain adequate output when it encounters increased demand, such as during exercise. As the condition progresses, patients can also experience symptoms like angina and syncope due to decreased cardiac output. Other conditions, while they may also present with murmurs or exertional dyspnea, do not typically present with the same signs as those seen in aortic stenosis. Thus, the clinical picture of a harsh midsystolic murmur along with exertional shortness of breath aligns well with a diagnosis of aortic stenosis, making it the most likely diagnosis in this scenario.