A 32-year-old man comes to the clinic after experiencing heart palpitations. He is concerned as his uncle died suddenly at age 35.
During physical examination, the physician asks the patient to sit up, lean forward, and hold his breath in full expiration while placing the diaphragm of the stethoscope at the left sternal border and applying firm pressure.
Which of the following findings is best auscultated with this maneuver?

Question

A 32-year-old man comes to the clinic after experiencing heart palpitations.  He is concerned as his uncle died suddenly at age 35.
During physical examination, the physician asks the patient to sit up, lean forward, and hold his breath in full expiration while placing the diaphragm of the stethoscope at the left sternal border and applying firm pressure.
Which of the following findings is best auscultated with this maneuver?

Quizplus · Accepted Answer

11ec193a_9764_dd53_853d_61b9e8c9419e_MD0002_00 The maneuver in the question is best suited for auscultating an aortic regurgitation murmur. Aortic regurgitation leads to an early decrescendo diastolic murmur that begins immediately after A2 (aortic component of second heart sound) and ends prior to the start of S1. The murmur is usually high pitched, blowing in quality, and best heard along the left sternal border at the 3rd and 4th intercostal space. Breath sounds can completely obscure the murmur in some patients. As a result, it is often best to instruct patients to sit up and lean forward while holding their breath in full expiration. Auscultation should be performed using the diaphragm of the stethoscope while applying firm pressure. (Choice B) Mitral valve prolapse (MVP) is associated with a single/multiple mid-systolic click and mid-to-late systolic murmur of mitral regurgitation. Standing or Valsalva causes an earlier systolic click and longer murmur (due to decreased left ventricular volume/size); squatting or leg elevation causes a delayed systolic click and shorter murmur (due to increased left ventricular volume/size). The maneuver performed on this patient does not affect mitral valve prolapse. Mitral valve prolapse (MVP) (Choice C) Mitral stenosis is associated with an opening snap (OS) of the mitral valve and a low-pitched rumbling murmur heard throughout diastole. This is best heard when the patient is in the left lateral decubitus position with the stethoscope bell at the cardiac apex. Mitral stenosis (Choice D) Pulmonic stenosis causes an ejection systolic click with an associated systolic ejection murmur that is best heard over the left second intercostal space with radiation to the left side of the neck. The closure of the pulmonary valve is delayed due to the stenosis, causing splitting of S2. Pulmonic stenosis intensity increases with inspiration and decreases with abrupt standing. Pulmonic stenosis (Choice E) A third heart sound (S3) is best heard when the patient is in the left lateral decubitus position with the stethoscope bell at the cardiac apex. Educational objective: Aortic regurgitation murmurs are best heard when the patient is sitting up, leaning forward, and holding their breath in full expiration while the diaphragm of the stethoscope is placed along the left sternal border at the 3rd or 4th intercostal space. __________ References: Valvular heart disease: aortic regurgitation. (http://www.ncbi.nlm.nih.gov/pubmed/15998697)

A 32-Year-Old Man Comes to the Clinic After Experiencing Heart