MEDizzy - A 20-year-old basketball player is seen for evaluation prior

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Disorders of the Cardiovascular System

A 20-year-old basketball player is seen for evaluation prior to beginning another season of competitive sports. A harsh systolic murmur is heard at the left lower sternal border. Which of the following maneuvers will enhance this murmur if hypertrophic cardiomyopathy is the underlying cause?

ExplanationHypertrophic cardiomyopathy usually presents between age 20 and 40 years, with the most common symptom being dyspnea. Many patients are, how - ever, asymptomatic and the only clue to the presence of this potentially deadly disease is physical examination. Physical examination will show a harsh systolic murmur heard best at the left lower sternal border arising from both the outflow tract turbulence during ven - tricular ejection and the often concomitant mitral regurgitation. Maneuvers that decrease ventricular volume such as Valsalva or moving from squatting to standing will enhance the murmur. Conversely, maneuvers that increase left ventricular volume will decrease the murmur’s intensity. These include hand grip and squatting. Having the patient lie with the left side down and leaning forward may make the friction rub of pericarditis more audible.