 Welcome back to our USMLE question of the week as always we start reading on the last sentence of the question so that we understand what it's asking. This patient has developed which of the following a 75 year old male with a past medical history of type 2 diabetes a body mass index of 30 and a previous myocardial infarction 15 years ago presents to the emergency department with crushing substernal chest pain readying to his neck and jaw. An ECG reveals ST segment elevation and leads V3 and V4 emergency cardiac catheterization with percutaneous coronary intervention or PCI shows a 99% occlusion of his left anterior descending artery. The patient remains stable after PCI and the echocardiography shows a mildly impaired ejection faction of 43%. Five days later the patient becomes acutely hypotensive and dysnick. The physical exam reveals a high-pitched holocystolic murmur loudest at the apex and radiating to the axilla that has not been present on previous exams. An emergency echo shows an ejection faction of 25%. The patient has developed which of the following. Well I know that we are dealing with one of the complications associated with myocardial infarctions. Specifically in this instance we're talking about five days after our myocardial infarction. There are three specific things that are associated with days 3 to 14 after myocardial infarction. Those three things are an intraventricular septal rupture, a left ventricular free wall rupture, and a papillary muscle rupture. Therefore I can rule out A, B, and F as possibilities as those do not fall within this normal timeframe. At this point in time to be able to distinguish between an intraventricular septum rupture, a left ventricular free wall rupture, and a papillary muscle rupture we need to look at furthermore into our symptoms. High-pitched holocystolic murmur that's loudest at the apex and radiates to the axilla. This sounds to me very much like a mitral valve regurgitation. If you remember your locations of where to listen to each valve sound and which heart sound, the apex of the heart is where you hear the mitral valve the best. Therefore to me we have mitral regurg associated with a myocardial infarction five days after we're dealing with a ruptured papillary muscle E. E is our correct answer. This patient has suffered a rupture of one of the papillary muscles in the left ventricle. This is a common complication that occurs within three to 14 days after a myocardial infarction. This papillary muscle anchors down the mitral valve keeping it from flopping back into the left atrium on systole. When the papillary muscle is damaged the mitral valve can flop back and allow regurgitation into the left atrium. This will cause a holocystolic blowing murmur that's going to be loudest at the apex and it will radiate to the axilla. This also will explain our reduced ejection fraction as our heart and our left ventricle are not pumping as much blood out of the heart as it is back into the left atrium. We're also seeing dyspnea in this patient that is classic signs of pulmonary edema due to the mitral regurg. The answer is not a ruptured left ventricular free wall because that typically will lead to tamponade and our ruptured intraventricular septum is going to lead us to a left to right shunt.