Question of the Week # 327

327) A 16 year old boy presents to your office for a Pre-participation sports physical examination. He is healthy and physically active and has no complaints. He has no chest pain or shortness of breath. He denies any drug use or smoking. His maternal grandfather recently died suddenly of cardiac arrest from severe Myocardial Infarction at age 82. On physical examination, he is afebrile, pulse 82/min, Respiratory rate 18/min and blood pressure 106/76 mm Hg. Chest is clear to auscultation. Cardiac examination reveals a mid-systolic murmur, grade 2/6 heard best along the left sternal border. The murmur decreases in intensity when he stands and increases when he is supine. S1 and S2 are normal. The second heart sound is physiologically split.  Cardiac impulse and carotid pulses are normal. The most appropriate action at this time:

A) Clear the patient for Sports participation

B) Refer to cardiology

C) Obtain 2D-Echocardiogram

D) Schedule Exercise Stress Test

E) Obtain Complete blood count

18 Responses

  1. C

  2. cccccccccccccccc echo

  3. C) Obtain 2D-Echocardiogram – HOCM

    • How does HOCM murmur vary with change in position? Remember any position that decreases blood flow hence decreases chamber size and should increase the sub-valvular obstruction in HOCM. On the other hand, supine position increases blood flow and increases the chamber size thereby, relieving some sub-valvular obstruction in HOCM. So, murmur is expected to increase while standing and decrease when supine in HOCM

      • Oh yes! u r right… so is it murmur due to anemia?

        E) Obtain Complete blood count

      • Thank you!

  4. I would rather confirm the diagnosis with 2-D echocardiogram than refering to cardiologist .Answer C

  5. c

  6. ccc

  7. c

  8. C…. Usmle galaxy, kindly tel da rite answer..

  9. c

  10. Correction is E

  11. it is MVP, it needs ECHO, Diagnosis of mitral valve prolapse is based on modern echocardiographic techniques which can pinpoint abnormal leaflet thickening and other related pathology.

  12. what is right ans DR. Red?

    How can I find the ans? How many books we suppose to read?

    my ans —bbbbbb

    all pediatric pt does not need echo—-that costly. referring cardiologist is not costly—-cardiologist find out either benign or pathologic?

    Let me know Dr. Red? am i right or wrong?

  13. He has innocent murmur. In children and adolescents, the diagnosis of an innocent heart murmur can be made if four criteria are met: absence of abnormal physical examination findings (except for the murmur); a negative review of systems (i.e., child is asymptomatic); a history that is negative for features that increase the risk of structural heart disease; and characteristic auscultatory features of a specific innocent heart murmur.2
    My answer is A:

  14. a

  15. (A) dr. Emerald u r a very good doctor

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