Cardiovascular

Question 1

Holosystolic murmur loudest at the apex, radiates to axilla. Most likely diagnosis?

Answer 1

Mitral regurgitation (MR)

Question 2

Mid/late diastolic murmur at apex. Most likely diagnosis?

Answer 2

Mitral Stenosis (MS)

Question 3

Mid/late systolic click at apex. Most likely diagnosis?

Answer 3

Mitral Valve Prolapse (MVP)

Question 4

Holosystolic murmur along left sternal border. Most likely diagnosis?

Answer 4

Tricuspid Regurgitation (TR) or Ventral Septal Defect (VSD)

Question 5

Systolic ejection murmur along left sternal border. Most likely diagnosis?

Answer 5

Hypertrophic cardiomyopathy (HCM)

Question 6

Diastolic murmur along lower left sternal border. Most likely diagnosis?

Answer 6

Tricuspid stenosis (TS) or atrial septal defect (ASD)

Question 7

Systolic ejection murmur best heard along upper left sternal border (2nd intercostal space). Most likely diagnosis?

Answer 7

Pulmonic stenosis (PS), flow murmur, or atrial septal defect (ASD)

Question 8

Systolic ejection click along upper left sternal border (2nd intercostal space). Most likely diagnosis?

Answer 8

Pulmonic stenosis (PS)

Question 9

Diastolic murmur along upper left sternal border (2nd intercostal space). Most likely diagnosis?

Answer 9

Aortic regurgitation (AR) or Pulmonic regurgitation (PR)

Question 10

Systolic ejection murmur along upper right sternal border. Most likely diagnosis?

Answer 10

Aortic stenosis (AS)

Question 11

Most common cause of chronic MR in developed countries?

Answer 11

Mitral valve prolapse

Question 12

Which maneuvers increase MVP murmur intensity and why?

Answer 12

Valsalva, abrupt standing.
These maneuvers decrease venous return to right heart ie. preload → less blood in heart, means smaller chamber sizes including LV → easier for leaflets to prolapse (bulge up into LA) → more turbulent backflow into LA → louder click → louder murmur.

Question 13

Which maneuvers decrease MVP murmur intensity and why?

Answer 13

Squatting from standing.
Squatting after standing causes increased venous return to heart and also increased afterload by kinking the femoral arteries. The increased venous return → increased preload → more blood in heart → larger size of chambers including LV → mitral leaflets are less likely to bulge (prolapse) into LA → less backflow (regurgitation) and less of a click heard → softer murmur

Question 14

Most commonly tested complication of chronic severe MR?

Answer 14

LAD (left atrial dilation) → atrial fibrillation → palpitations felt by patient

Question 15

Which maneuvers increase HCM murmur intensity and why?

Answer 15

Valsalva (strain phase), abrupt standing, amyl nitrate administration.
These maneuvers decrease preload → less blood in LV means smaller chamber size and narrow LVOT opening for blood to pass → more turbulent flow → louder murmur.

Question 16

Which maneuvers decrease HCM murmur intensity and why?

Answer 16

Squatting from standing position (increases preload and afterload), leg raise (increases preload), sustained hand grip (increases afterload).
These maneuvers by increasing afterload or preload → increased chamber size → larger LVOT for blood to pass through → less turbulent flow → softer murmur.

Question 17

What causes hypertrophic cardiomyopathy (HCM)?

Answer 17

Autosomal dominant disease → Asymmetrical LVH → LVOT obstruction.

Question 18

Expected presenting symptoms for hypertrophic cardiomyopathy (HCM) based on pathophysiology?

Answer 18

LVOT obstruction → less blood to brain/body → dyspnea, chest pain, palpitations, syncope. May have carotid pulse with dual upstroke due to midsystolic obstruction during cardiac contraction.