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{{WBRQuestion
{{WBRQuestion
|QuestionAuthor={{Rim}} {{Alison}}
|QuestionAuthor={{YD}} (Reviewed by {{YD}} and {{AJL}})
|ExamType=USMLE Step 1
|ExamType=USMLE Step 1
|MainCategory=Physiology
|MainCategory=Physiology
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|MainCategory=Physiology
|MainCategory=Physiology
|SubCategory=Cardiology
|SubCategory=Cardiology
|MainCategory=Physiology
|MainCategory=Physiology
|MainCategory=Physiology
|MainCategory=Physiology
|MainCategory=Physiology
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|MainCategory=Physiology
|MainCategory=Physiology
|SubCategory=Cardiology
|SubCategory=Cardiology
|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?
|Prompt=A 25-year-old man with a history of hypertrophic obstructive cardiomyopathy (HOCM) presents to the cardiologist’s office for an annual-check up. Physical examination is remarkable for a murmur upon cardiac auscultation. Which of the following bedside maneuvers will most likely increase the intensity of this patient’s murmur?
|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]].
|Explanation=A [[valsalva's maneuver]] is done when a patient stands from a seated position. Valsalva's maneuver decreases venous return and preload. The majority of heart [[murmurs]] decrease in intensity upon [[valsalva's maneuver]] with the exception of murmurs caused by [[mitral valve prolapse]] (MVP) and [[HOCM]].
 
|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
 
 
|AnswerA=Standing from a seated position
|AnswerA=Standing from a seated position
|AnswerAExp=Standing from a seated position, a [[valsalva maneuver]], will increase the intensity of HCM.
|AnswerAExp=Standing from a seated position (valsalva's maneuver) increases the intensity of murmur caused by HOCM.
|AnswerB=Clenching fists forcefully
|AnswerB=Clenching fists forcefully
|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.
|AnswerBExp=Clenching fists forcefully (hand grip) increases 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 a [[valsalva maneuver]]. It will increase preload and decrease the intensity of the HCM murmur.
|AnswerCExp=Lying in supine position and raising legs upwards is the opposite of a [[valsalva's maneuver]]. It will increase preload and decrease the intensity of the HOCM murmur.
|AnswerD=Rapid squatting
|AnswerD=Rapid squatting
|AnswerDExp=Rapid squatting increases preload and afterload, but decreases the intensity of the HCM murmur.
|AnswerDExp=Rapid squatting increases both preload and afterload. Generally, it decreases the intensity of the HOCM murmur.
|AnswerE=Lying in the left lateral decubitus position
|AnswerE=Lying in the left lateral decubitus position
|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.
|AnswerEExp=Lying in the left lateral decubitus position may help in the auscultation of murmurs caused by mitral stenosis (MS), commonly a complication of rheumatic heart disease. Auscultation using the bell of the stethoscope while patients are in a left lateral decubitus position may also identify S3 sounds, which are late diastolic, low-frequency sounds.  
|EducationalObjectives=The majority of heart [[murmurs]] decrease in intensity upon [[valsalva's maneuver]] with the exception of murmurs caused by [[mitral valve prolapse]] (MVP) and [[HOCM]].
|References=First Aid 2014 page 272
|RightAnswer=A
|RightAnswer=A
|WBRKeyword= Valsalva maneuver, murmur, hypertrophic cardiomyopathy, HCM, preload, cardiology, cardiovascular  
|WBRKeyword=Valsalva maneuver, murmur, hypertrophic cardiomyopathy, HCM, preload, cardiology, cardiovascular
|Approved=Yes
|Approved=Yes
}}
}}

Revision as of 16:52, 20 February 2015
Author [[PageAuthor::Yazan Daaboul, M.D. (Reviewed by Yazan Daaboul, M.D. and Alison Leibowitz [1])]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Physiology
Sub Category SubCategory::Cardiology
Prompt [[Prompt::A 25-year-old man with a history of hypertrophic obstructive cardiomyopathy (HOCM) presents to the cardiologist’s office for an annual-check up. Physical examination is remarkable for a murmur upon cardiac auscultation. 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 (valsalva's maneuver) increases the intensity of murmur caused by HOCM.
Answer B AnswerB::Clenching fists forcefully
Answer B Explanation AnswerBExp::Clenching fists forcefully (hand grip) increases 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's maneuver. It will increase preload and decrease the intensity of the HOCM murmur.]]
Answer D AnswerD::Rapid squatting
Answer D Explanation AnswerDExp::Rapid squatting increases both preload and afterload. Generally, it decreases the intensity of the HOCM murmur.
Answer E AnswerE::Lying in the left lateral decubitus position
Answer E Explanation [[AnswerEExp::Lying in the left lateral decubitus position may help in the auscultation of murmurs caused by mitral stenosis (MS), commonly a complication of rheumatic heart disease. Auscultation using the bell of the stethoscope while patients are in a left lateral decubitus position may also identify S3 sounds, which are late diastolic, low-frequency sounds.]]
Right Answer RightAnswer::A
Explanation [[Explanation::A valsalva's maneuver is done when a patient stands from a seated position. Valsalva's maneuver decreases venous return and preload. The majority of heart murmurs decrease in intensity upon valsalva's maneuver with the exception of murmurs caused by mitral valve prolapse (MVP) and HOCM.

Educational Objective: The majority of heart murmurs decrease in intensity upon valsalva's maneuver with the exception of murmurs caused by mitral valve prolapse (MVP) and HOCM.
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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