WBR0427
| 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. |
| 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:: |