WBR0427
| 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. |
| 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:: |