{"id":6140,"date":"2025-06-25T00:01:00","date_gmt":"2025-06-25T08:01:00","guid":{"rendered":"https:\/\/www.osmosis.org\/blog\/?p=6140"},"modified":"2025-10-01T11:38:25","modified_gmt":"2025-10-01T19:38:25","slug":"usmle-step-2-ck-question-of-the-day-holosystolic-murmur","status":"publish","type":"post","link":"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-holosystolic-murmur","title":{"rendered":"USMLE\u00ae Step 2 CK Question of the Day:\u00a0Holosystolic murmur"},"content":{"rendered":"<div id=\"ez-toc-container\" class=\"ez-toc-v2_0_80 ez-toc-wrap-center counter-hierarchy ez-toc-counter ez-toc-custom ez-toc-container-direction\">\n<div class=\"ez-toc-title-container\">\n<p class=\"ez-toc-title\" style=\"cursor:inherit\">In This Article<\/p>\n<span class=\"ez-toc-title-toggle\"><a href=\"#\" class=\"ez-toc-pull-right ez-toc-btn ez-toc-btn-xs ez-toc-btn-default ez-toc-toggle\" aria-label=\"Toggle Table of Content\"><span class=\"ez-toc-js-icon-con\"><span class=\"\"><span class=\"eztoc-hide\" style=\"display:none;\">Toggle<\/span><span class=\"ez-toc-icon-toggle-span\"><svg style=\"fill: #999;color:#999\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" class=\"list-377408\" width=\"20px\" height=\"20px\" viewBox=\"0 0 24 24\" fill=\"none\"><path d=\"M6 6H4v2h2V6zm14 0H8v2h12V6zM4 11h2v2H4v-2zm16 0H8v2h12v-2zM4 16h2v2H4v-2zm16 0H8v2h12v-2z\" fill=\"currentColor\"><\/path><\/svg><svg style=\"fill: #999;color:#999\" class=\"arrow-unsorted-368013\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"10px\" height=\"10px\" viewBox=\"0 0 24 24\" version=\"1.2\" baseProfile=\"tiny\"><path d=\"M18.2 9.3l-6.2-6.3-6.2 6.3c-.2.2-.3.4-.3.7s.1.5.3.7c.2.2.4.3.7.3h11c.3 0 .5-.1.7-.3.2-.2.3-.5.3-.7s-.1-.5-.3-.7zM5.8 14.7l6.2 6.3 6.2-6.3c.2-.2.3-.5.3-.7s-.1-.5-.3-.7c-.2-.2-.4-.3-.7-.3h-11c-.3 0-.5.1-.7.3-.2.2-.3.5-.3.7s.1.5.3.7z\"\/><\/svg><\/span><\/span><\/span><\/a><\/span><\/div>\n<nav><ul class='ez-toc-list ez-toc-list-level-1 ' ><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-1\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-holosystolic-murmur\/#The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\" >The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-2\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-holosystolic-murmur\/#Incorrect_Answer_Explanations\" >Incorrect Answer Explanations<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-3\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-holosystolic-murmur\/#Main_Explanation\" >Main Explanation<\/a><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-4\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-holosystolic-murmur\/#Major_Takeaway\" >Major Takeaway&nbsp;<\/a><ul class='ez-toc-list-level-3' ><li class='ez-toc-heading-level-3'><a class=\"ez-toc-link ez-toc-heading-5\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-holosystolic-murmur\/#Want_to_learn_more_about_this_topic\" >Want to learn more about this topic?<\/a><\/li><\/ul><\/li><li class='ez-toc-page-1 ez-toc-heading-level-2'><a class=\"ez-toc-link ez-toc-heading-6\" href=\"https:\/\/www.osmosis.org\/blog\/usmle-step-2-ck-question-of-the-day-holosystolic-murmur\/#References\" >References&nbsp;<\/a><\/li><\/ul><\/nav><\/div>\n\n<p class=\"wp-block-paragraph\"><strong><em>Today, we\u2019re examining a clinical case of a 35-year-old woman in the emergency department who reports three weeks of severe lower back pain that&#8217;s worse with movement, as well as chills and intermittent fevers. What&#8217;s the likely cause?<\/em><\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A 35-year-old woman presents to the emergency department for three weeks of severe lower back pain that is worse with movement, chills, and intermittent fevers. She has a history of injection drug use. Temperature is 39.2\u00b0C (102.6\u00b0F), heart rate is 112\/min, blood pressure is 120\/80 mm Hg, and respiratory rate is 22\/min. Physical examination reveals tenderness over the lumbar spine at L3 and a 4\/6 holosystolic murmur is best heard at the left sternal border. Neurological examination is within normal limits. Laboratory findings are significant for a white blood cell (WBC) count of 15,500\/\u03bcL, C-reactive protein (CRP) of 130 mg\/L, and an erythrocyte sedimentation rate (ESR) of 120 mm\/h. Spine x-rays show L3 vertebral body destruction and collapse of the intervertebral disc space. <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Which of the following organisms is the most likely cause of this patient\u2019s condition?<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Staphylococcus aureus<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Coxiella burnetii<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Streptococcus mutans<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Candida albicans<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Mycobacterium tuberculosis<\/strong><\/p>\n\n\n\n<p class=\"has-text-align-center wp-block-paragraph\"><em>Scroll down for the correct answer!<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"The_correct_answer_to_todays_USMLE%C2%AE_Step_2_Question_is%E2%80%A6\"><\/span>The correct answer to today\u2019s USMLE\u00ae Step 2 Question is\u2026<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>A. Staphylococcus aureus<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">See Main Explanation.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Incorrect_Answer_Explanations\"><\/span>Incorrect Answer Explanations<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>B. Coxiella burnetii<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Coxiella burnetii, the causative agent of Q fever, can lead to endocarditis, primarily in patients with chronic disease or certain occupational exposures like livestock handling. However, Staphylococcus aureus is the most likely cause of osteomyelitis associated with endocarditis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C. Streptococcus mutans<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> While Streptococcus mutans is associated with endocarditis, it is not a common cause of osteomyelitis. Staphylococcus aureus is the most likely cause of osteomyelitis associated with endocarditis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>D. Candida albicans<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Candida albicans can cause chronic osteomyelitis, primarily in immunocompromised patients or in patients with prolonged central venous access. This patient&#8217;s lack of evident immunosuppression and acute presentation make Candida a less likely pathogen. Staphylococcus aureus is the most likely cause of osteomyelitis associated with endocarditis.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>E. Mycobacterium tuberculosis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Incorrect:<\/strong> Mycobacterium tuberculosis can cause spinal tuberculosis (Pott\u2019s disease), but it typically presents with a more chronic course. Staphylococcus aureus is the most likely cause of osteomyelitis associated with endocarditis. US guided biopsy should be performed and cultures should test for Mycobacterium tuberculosis to rule it out.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Main_Explanation\"><\/span>Main Explanation<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"624\" height=\"311\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/07\/image_8617b4.png\" alt=\"Causes:\nStephylococcus aureus\nMycobacterium tuberculosis\nPseudomonas aeruginosa\nStreptococcus spp\nSalmonella\nPasteurella\nViruses\nParasites\nFungi\" class=\"wp-image-6143\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/07\/image_8617b4.png 624w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2025\/07\/image_8617b4.png?resize=300,150 300w\" sizes=\"auto, (max-width: 624px) 100vw, 624px\" \/><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\">The patient&#8217;s presentation of <strong>acute lower back pain and tenderness<\/strong>, fevers and chills, history of <strong>intravenous drug use<\/strong>, and x-ray findings suggests <strong>acute vertebral osteomyelitis<\/strong>. The presence of a <strong>4\/6 holosystolic murmur<\/strong> raises concern for <strong>infective endocarditis<\/strong> with<strong> bacteremia <\/strong>and<strong> hematogenous spread <\/strong>to the vertebral column. <strong><em>Staphylococcus aureus<\/em><\/strong> is the most common cause of osteomyelitis in patients who use IV drugs, and it is known for its aggressive nature and propensity to affect bones and heart valves.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Patients with <strong>acute osteomyelitis<\/strong> typically exhibit <strong>localized pain at the infection site,<\/strong> often accompanied by<strong> tenderness, swelling, and warmth<\/strong>. <strong>Systemic symptoms<\/strong> such as fevers and chills frequently occur. In <strong>chronic osteomyelitis<\/strong>, symptoms can be more <strong>subtle and insidious<\/strong>, such as a continuous dull ache or localized discomfort at the site of infection. <strong>Intravenous drug use<\/strong> is a risk factor for vertebral osteomyelitis. Patients can present with severe back pain, fever, chills, weight loss, and neurological signs and symptoms such as incontinence or focal neurologic deficits.&nbsp;&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Major_Takeaway\"><\/span>Major Takeaway&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\"><em>Staphylococcus aureus<\/em> is the most common cause of osteomyelitis in general and the most common cause of osteomyelitis in patients who use intravenous drugs. Patients with vertebral osteomyelitis typically present with severe localized back pain and systemic symptoms, with or without neurologic findings.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"Want_to_learn_more_about_this_topic\"><\/span>Want to learn more about this topic?<span class=\"ez-toc-section-end\"><\/span><\/h3>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Watch the Osmosis video:<\/strong> <strong><a href=\"https:\/\/www.osmosis.org\/learn\/Osteomyelitis:_Clinical_sciences\" target=\"_blank\" rel=\"noreferrer noopener\">Osteomyelitis: Clinical sciences<\/a><\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><span class=\"ez-toc-section\" id=\"References\"><\/span>References&nbsp;<span class=\"ez-toc-section-end\"><\/span><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Berbari EF, Kanj SS, Kowalski TJ, et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015;61(6):e26-e46. doi:10.1093\/cid\/civ482<\/li>\n<\/ul>\n\n\n\n<figure class=\"wp-block-image aligncenter size-full\"><a href=\"https:\/\/www.osmosis.org\/plans\/md\"><img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"250\" src=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_GENERAL3_2023.png\" alt=\"\" class=\"wp-image-4447\" srcset=\"https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_GENERAL3_2023.png 700w, https:\/\/www.osmosis.org\/blog\/wp-content\/uploads\/sites\/2\/2021\/03\/Blog_Display_Ads_GENERAL3_2023.png?resize=300,107 300w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/a><\/figure>\n\n\n\n<p class=\"wp-block-paragraph\"><em><strong>Want more USMLE\u00ae Step 2 CK practice questions? Try Osmosis by Elsevier today! Access your&nbsp;<em><strong><a href=\"https:\/\/www.osmosis.org\/login?type=create\" target=\"_blank\" rel=\"noreferrer noopener\">free trial<\/a><\/strong><\/em>&nbsp;and discover why millions of current and future clinicians and caregivers love learning with us.<\/strong><\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Explore today\u2019s USMLE\u00ae Step 2 CK question on a case of holosystolic murmur and learn the most likely organism causing it.<\/p>\n","protected":false},"author":202,"featured_media":6144,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_feature_clip_id":0,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_post_was_ever_published":false},"categories":[27,20,16,1366,45],"tags":[796,810,265,808,614,84,807,806,809,185],"class_list":["post-6140","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medicine","category-exam-prep","category-do","category-questions","category-step-2","tag-clinical-management","tag-endocarditis","tag-healthcare-training","tag-holosystolic-murmur","tag-infectious-diseases","tag-medical-education","tag-osteomyelitis","tag-pediatric-case","tag-staphylococcus-aureus","tag-usmle"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v23.6 - 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