Acyanotic congenital heart defects Quiz: Ace Your Exams

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A 35-year-old woman comes to the emergency room for evaluation of left-sided weakness and slurred speech that began three hours ago. She is currently taking oral contraceptives. Medical history is otherwise unremarkable. She has a 8 pack-year smoking history. Temperature is 37.5°C (99.5°F), pulse is 71/min and blood pressure is 127/81 mmHg. BMI is 36 kg/m2. Physical examination shows motor strength of ⅗ on the left side. Cardiac exam reveals a systolic murmur loudest at the left upper sternal border and fixed-splitting of the S2 heart sound. Extremity examination reveals swelling and erythema in the right calf. MRI of the brain shows signs of an ischemic infarction. Which of the following best explains the finding observed in this patient? 

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