A 42-year-old woman comes to the clinic for a routine physical examination. She has no specific concerns, but on review of systems acknowledges that she has recently been getting tired easily. The patient also informs the physician of occasional palpitations, which she describes as a "fast heartbeat." Family history is significant for hypertension and type 2 diabetes mellitus. She is a lifetime nonsmoker. The patient does not drink alcohol or use illicit drugs. Vital signs are normal. She was told in the past that she has "a heart problem" that she thinks is mitral valve prolapse. The patient was advised to follow-up with a cardiologist, but she says she had been feeling well and did not see a doctor. Which of the following physical findings would be most consistent with this diagnosis?
A)Ejection click followed by a crescendo-decrescendo systolic murmur
B)Harsh holosystolic murmur with the thrill at the left sternal border
C)Holosystolic murmur at the lower sternum that increases with inspiration
D)Loud S1 and low-pitched diastolic murmur loudest at apex
E)Nonejection click and murmur that vary in timing depending on body position

Question

A 42-year-old woman comes to the clinic for a routine physical examination.  She has no specific concerns, but on review of systems acknowledges that she has recently been getting tired easily.  The patient also informs the physician of occasional palpitations, which she describes as a "fast heartbeat."  Family history is significant for hypertension and type 2 diabetes mellitus.  She is a lifetime nonsmoker.  The patient does not drink alcohol or use illicit drugs.  Vital signs are normal.  She was told in the past that she has "a heart problem" that she thinks is mitral valve prolapse.  The patient was advised to follow-up with a cardiologist, but she says she had been feeling well and did not see a doctor.  Which of the following physical findings would be most consistent with this diagnosis?
A)Ejection click followed by a crescendo-decrescendo systolic murmur
B)Harsh holosystolic murmur with the thrill at the left sternal border
C)Holosystolic murmur at the lower sternum that increases with inspiration
D)Loud S1 and low-pitched diastolic murmur loudest at apex
E)Nonejection click and murmur that vary in timing depending on body position

Quizplus · Accepted Answer

Explanation: 11ec2b69_c11c_23fc_8f63_878ff77196ca_MD0005_00 Cardiac auscultation in patients with mitral valve prolapse (MVP) typically reveals a nonejection click due to snapping of the mitral chordae as the valve cusps extend into the atrium during systole, followed by a systolic murmur of mitral regurgitation. In each patient with MVP there is a critical left ventricular size at which prolapse occurs during ventricular contraction; therefore, the timing of the click and murmur during systole varies depending on left ventricular end-diastolic volume (LVEDV). With increased venous return (eg, squatting, supine leg raise), LVEDV is relatively high and the critical point at which prolapse occurs is reached late in systole or may not be reached at all (disappearance of the click). In contrast, maneuvers that decrease venous return (eg, standing, Valsalva) result in relatively low LVEDV, earlier reaching of the critical prolapse point during systole, and an earlier click and murmur. In general, a critical point that occurs at a relatively large left ventricular size is consistent with more severe MVP. Unlike MVP, most other murmurs become more prominent in the setting of increased venous return. Another exception that, like MVP, becomes less prominent with increased venous return is the systolic murmur of hypertrophic cardiomyopathy. murmurs (Choice A) An ejection (rather than nonejection) click followed by a crescendo-decrescendo systolic murmur is heard in patients with aortic or pulmonic valve stenosis; the murmur increases in intensity with increased venous return. The systolic murmur of mitral regurgitation is constant rather than crescendo-decrescendo. (Choice B) A harsh holosystolic murmur with maximal intensity over the left third and fourth intercostal space with a palpable thrill is heard in patients with a ventricular septal defect. (Choice C) A holosystolic murmur at the lower sternum that increases with inspiration is heard in patients with tricuspid regurgitation. (Choice D) Cardiac auscultation findings in patients with mitral stenosis include an accentuated S1 (mitral valve closure), an opening snap heard after S2, and a low-pitched mid-diastolic murmur best heard at the cardiac apex. Educational objective: Cardiac auscultation in patients with mitral valve prolapse typically reveals a nonejection click and a systolic murmur of mitral regurgitation. The click and murmur occur later in systole as left ventricular end-diastolic volume increases and in some patients may disappear completely in the setting of large-volume venous return. References: Mitral valve prolapse with a late-systolic regurgitant murmur may be associated with significant hemodynamic consequences. (http://www.ncbi.nlm.nih.gov/pubmed/19561453)

A 42-Year-Old Woman Comes to the Clinic for a Routine