Medical Mystery of the Week

 You are asked to see this 55-year-old man to evaluate the cause of persistent fever. You make a diagnosis merely by examining his oropharynx (the video may take several seconds to upload) .

DIAGNOSIS: Widened pulse pressure (≥ 65 mm Hg), in this case, due to aortic valve endocarditis. The video demonstrates a positive Muller's sign (systolic pulsation of the uvula seen in patients with very wide pulse pressures of whatever cause; note also the prominent pulsations of the internal carotid arteries in the oropharynx). Other signs of a widened pulse pressure include:1. Corrigan-Watson "water-hammer" pulse (a bounding radial pulse, often associated with a "pistol shot" murmur heard over the artery); 2. Quincke pulse  (systolic pulsation of subungual capillaries seen best upon applying slight pressure to a fingernail); 3. Duroziez sign (positive when stethoscope pressure over the femoral artery produces both a systolic and diastolic murmur); 4. Systolic head bobbing; and 5. pulsus bisferiens..  

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