WBR0427
| Author | [[PageAuthor::Rim Halaby, M.D. [1]]] |
|---|---|
| Exam Type | ExamType::USMLE Step 1 |
| Main Category | MainCategory::Physiology |
| Sub Category | SubCategory::Cardiology |
| Prompt | [[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?]] |
| Answer A | AnswerA::Standing from a seated position |
| Answer A Explanation | AnswerAExp::Standing from a seated position is an example of valsalva maneuver that 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 thus increase 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 valsalva maneuver. It will increase preload and decrease the intensity of HCM murmur. |
| Answer D | AnswerD::Rapid squatting |
| Answer D Explanation | AnswerDExp::Rapid squatting increases both preload and afterload because it increases venous return and increases afterload, respectively. It decreases the intensity of HCM murmur. |
| Answer E | AnswerE::Lying in the left lateral decubitus position |
| Answer E Explanation | [[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.]] |
| Right Answer | RightAnswer::A |
| Explanation | [[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.
Educational Objective:
Valsalva maneuver that decreases preload and can be achieved by standing from a seated position, can increase the intensity of HCM murmur. |
| Approved | Approved::No |
| Keyword | WBRKeyword::Valsalva, WBRKeyword::murmur, WBRKeyword::hypertrophic, WBRKeyword::cardiomyopathy, WBRKeyword::preload, WBRKeyword::afterload |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |