This patient has upon auscultation of the aortic area clear aortic stenosis (AS) and regurgitation (AR) (or aortic valve incompetence).

Aortic stenosis causes reversed splitting of the 2nd heart sound due to delayed closure of the aortic valve. There in prominent splitting of the 2nd heart sound  during expiration due to the pulmonary valve closing prior to the aortic. In inspiration, there is virtually no split (or minor) in the 2nd heart sound due to the pulmonary valve being delayed in closure.

The patient presented here has both aortic stenosis and aortic valve incompetence, and hence both systolic and diastolic murmurs can be heard. You cannot hear any of the 2nd heart sound.

Other associated clinical features:

  • regular pulse
  • slowing rising pulse (AS dominant)
  • collapsing pulse (AR dominant)
  • normal JVP
  • palpable apex beat, displaced laterally of the mid-clavicular line
  • forceful heave that is sustained (AS)
  • thrusting apex beat in mid-axillary line (AR)
  • palpable systolic thrill at the displaced apex, aortic and carotid areas (AS)
  • low pulse pressure (AS dominant)
  • wide pulse pressure (AR dominant)