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Created page with "{{WBRQuestion |QuestionAuthor={{Rim}} |ExamType=USMLE Step 1 |MainCategory=Physiology |SubCategory=Cardiology |MainCategory=Physiology |SubCategory=Cardiology |MainCategory=Ph..."
 
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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}}
|QuestionAuthor={{Rim}} {{Alison}}
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Physiology
|MainCategory=Physiology
Line 20: Line 20:
|MainCategory=Physiology
|MainCategory=Physiology
|SubCategory=Cardiology
|SubCategory=Cardiology
|Prompt=A 25 year old male patient, with a history of hypertrophic cardiomyopathy (HCM), presents to his cardiologist’s office for his annual-check up.  On physical examination, the physician auscultates a murmur.  Which of the following bedside maneuvers will most likely increase the intensity of this patient’s murmur?
|Prompt=A 25-year-old male, with a history of hypertrophic cardiomyopathy (HCM), presents to the cardiologist’s office for an annual-check up.  Upon physical examination, you auscultate a murmur.  Which of the following bedside maneuvers will most likely increase the intensity of this patient’s murmur?
|Explanation=[[Valsalva]] [[maneuver]] is characterized by decreasing venous return and thus [[preload]].  It can be achieved when the patient stands from a seated position.  Most heart [[murmurs]] decrease in intensity when performing valsalva maneuvers with the exception of [[mitral valve prolapse]] (MVP) and [[HCM]].
|Explanation= A [[valsalva maneuver]], characterized by decreasing venous return and [[preload]], may occur when a patient stands from a seated position.  Most heart [[murmurs]] decrease in intensity upon [[valsalva maneuver]]s with the exception of [[mitral valve prolapse]] (MVP) and [[HCM]].
 
|EducationalObjectives=
A [[valsalva maneuver]], characterized by decreasing venous return and [[preload]], may occur when a patient stands from a seated position.  Most heart [[murmurs]] decrease in intensity upon [[valsalva maneuver]]s with the exception of [[mitral valve prolapse]] (MVP) and [[HCM]].
|References= First Aid 2014 page 272


Educational Objective:
Valsalva maneuver that decreases preload and can be achieved by standing from a seated position, can increase the intensity of HCM murmur.


|AnswerA=Standing from a seated position
|AnswerA=Standing from a seated position
|AnswerAExp=Standing from a seated position is an example of valsalva maneuver that will increase the intensity of HCM.
|AnswerAExp=Standing from a seated position, a [[valsalva maneuver]], will increase the intensity of HCM.
|AnswerB=Clenching fists forcefully   
|AnswerB=Clenching fists forcefully   
|AnswerBExp=Clenching fists forcefully, or hand grip, will increase systemic vascular resistance and thus increase afterload.  Mitral regurgitation (MR) and ventricular septal defect (VSD) murmur intensities increase with hand grip.
|AnswerBExp=Clenching fists forcefully, or hand grip, will increase systemic vascular resistance and afterload.  Mitral regurgitation (MR) and ventricular septal defect (VSD) murmur intensities increase with hand grip.
|AnswerC=Lying in supine position and raising legs upwards
|AnswerC=Lying in supine position and raising legs upwards
|AnswerCExp=Lying in supine position and raising legs upwards is the opposite of valsalva maneuver.  It will increase preload and decrease the intensity of HCM murmur.
|AnswerCExp=Lying in supine position and raising legs upwards is the opposite of a [[valsalva maneuver]].  It will increase preload and decrease the intensity of the HCM murmur.
|AnswerD=Rapid squatting
|AnswerD=Rapid squatting
|AnswerDExp=Rapid squatting increases both preload and afterload because it increases venous return and increases afterload, respectively.  It decreases the intensity of HCM murmur.
|AnswerDExp=Rapid squatting increases preload and afterload, but decreases the intensity of the HCM murmur.
|AnswerE=Lying in the left lateral decubitus position
|AnswerE=Lying in the left lateral decubitus position
|AnswerEExp=Lying in the lateral decubitus position is helpful to identify mitral stenosis (MS), commonly a complication of rheumatic heart disease and S3 sounds, which are low frequency sounds that occur in late diastole.  S3 is best heard using the bell of the stethoscope.  S3 is classically heard in heart failure in the elderly; whereas it can be a normal finding in the young and in pregnant women.
|AnswerEExp=Lying in the lateral decubitus position aids in the identification of mitral stenosis (MS), commonly a complication of rheumatic heart disease and S3 sounds, which are low frequency sounds that occur in late diastole.  Best heard using the bell of a stethoscope, S3 frequently manifests with heart failure in the elderly. S3 can be a normal finding in children and pregnant women.
|RightAnswer=A
|RightAnswer=A
|WBRKeyword=Valsalva, murmur, hypertrophic, cardiomyopathy, preload, afterload
|WBRKeyword= Valsalva maneuver, murmur, hypertrophic cardiomyopathy, HCM, preload, cardiology, cardiovascular
|Approved=No
|Approved=Yes
}}
}}

Revision as of 17:28, 21 July 2014
Author [[PageAuthor::Rim Halaby, M.D. [1] (Reviewed by Alison Leibowitz)]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Physiology
Sub Category SubCategory::Cardiology
Prompt [[Prompt::A 25-year-old male, with a history of hypertrophic cardiomyopathy (HCM), presents to the cardiologist’s office for an annual-check up. Upon physical examination, you auscultate a murmur. Which of the following bedside maneuvers will most likely increase the intensity of this patient’s murmur?]]
Answer A AnswerA::Standing from a seated position
Answer A Explanation [[AnswerAExp::Standing from a seated position, a valsalva maneuver, will increase the intensity of HCM.]]
Answer B AnswerB::Clenching fists forcefully
Answer B Explanation AnswerBExp::Clenching fists forcefully, or hand grip, will increase systemic vascular resistance and afterload. Mitral regurgitation (MR) and ventricular septal defect (VSD) murmur intensities increase with hand grip.
Answer C AnswerC::Lying in supine position and raising legs upwards
Answer C Explanation [[AnswerCExp::Lying in supine position and raising legs upwards is the opposite of a valsalva maneuver. It will increase preload and decrease the intensity of the HCM murmur.]]
Answer D AnswerD::Rapid squatting
Answer D Explanation AnswerDExp::Rapid squatting increases preload and afterload, but decreases the intensity of the HCM murmur.
Answer E AnswerE::Lying in the left lateral decubitus position
Answer E Explanation [[AnswerEExp::Lying in the lateral decubitus position aids in the identification of mitral stenosis (MS), commonly a complication of rheumatic heart disease and S3 sounds, which are low frequency sounds that occur in late diastole. Best heard using the bell of a stethoscope, S3 frequently manifests with heart failure in the elderly. S3 can be a normal finding in children and pregnant women.]]
Right Answer RightAnswer::A
Explanation [[Explanation::A valsalva maneuver, characterized by decreasing venous return and preload, may occur when a patient stands from a seated position. Most heart murmurs decrease in intensity upon valsalva maneuvers with the exception of mitral valve prolapse (MVP) and HCM.

Educational Objective: A valsalva maneuver, characterized by decreasing venous return and preload, may occur when a patient stands from a seated position. Most heart murmurs decrease in intensity upon valsalva maneuvers with the exception of mitral valve prolapse (MVP) and HCM.
References: First Aid 2014 page 272]]

Approved Approved::Yes
Keyword WBRKeyword::Valsalva maneuver, WBRKeyword::murmur, WBRKeyword::hypertrophic cardiomyopathy, WBRKeyword::HCM, WBRKeyword::preload, WBRKeyword::cardiology, WBRKeyword::cardiovascular
Linked Question Linked::
Order in Linked Questions LinkedOrder::
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