macintosh
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A 22-year-old female first-year medical student visits her physician for a new-patient visit. She has no health complaints. The patient's family history includes a healthy mother and brother, but her father died at age 53 years from an aortic dissection. Physical examination shows that the patient is 180 cm (71 in) tall and 61 kg (135 lb); her blood pressure is 115/70 mm Hg and her heart rate is 64/min. Cardiac auscultation reveals a systolic click. What physical manipulations can help to exaggerate this click?
© A. Deep breaths
© B. Exhaling
© C. Lying down
© D. Squatting
© E. Valsalva maneuver
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| maoudoody
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c
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| macintosh
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Lying down increase blood flow to the right heart. This should not exagerate the click, as it is present in the left heart.
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| maoudoody
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well all the choices will increase venous return except for exhaling
so i guess it is the right answer
in goljan he said that decreasing preload makes the systoloc murmur and click of mitralvalve prolaplse moves closer to s1
and increasing preload makes it moves closer to s2
but he said nothing about making the click louder
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| arlete
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Anything that increases the LV volume will stretch the mitral ring, therefore the leaflets and decrease the click. So: deep breaths, lying down, squatting, Valsalva maneuver.
So I think it's B.
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| Ig F
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yes exhaling decreases the left ventricle volume...but at the same time atria are being filled...which causes mitral valve to prolapse...producing systolic click...
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| macintosh
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The correct answer is e
The patients history suggests marfan's syndrome. In this case the systolic click is really the mid-systolic-click associated with the mitral valve prolapse. the click is heard in the redundant mitral valve as it opens. Performing valsalva increases the intraabdominal and intrathoracic pressure. with more pressure otside the heart, the click shoiuld accentuate. Excercise may have a similar effect. Sudden squatting may increase the blood flow to the right heart and therefore decrease the sound heard in mid systolic click.
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| macintosh
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Alternatively here is the given answer:
Explanation
The correct answer is E. The physical characteristics of this woman and her father's medical history most likely point to Marfan's syndrome. Marian's syndrome is associated with a high prevalence of mitral valve prolapse (MVP). The Valsalva maneuver causes an increase in abdominal and thoracic pressure. This exaggerates the external pressure on the heart, increasing the audibility ofthe mid-systolic click associated with mitral valve prolapse by causing a louder snap in response to ventricular pressures.
A is not correct. When one is listening to the splitting of S2, deep breaths can help distinguish the different aortic and pulmonic sounds, not the mitral valve sound.
B is not correct. Pericardial friction rubs are best heard during expiration.
C is not correct. Lying down does not exaggerate any valve sounds.
D is not correct. Squatting reduces the mid-systolic click associated with mitral valve prolapse.
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| arlete
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Good question, thanks! 
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