A nurse auscultates the heart of Anu, a 21-year-old female. Anu seeks a consultation for dizziness and easy fatigability. During assessment, the nurse identifies a mid-to-late systolic click followed with mid-to-late systolic murmur at the cardiac apex. The murmur gets louder when she stands up. Based on these findings, Anu is most likely considered for which of the following cardiac problems?

1. A

   Aortic stenosis

2. B

   Mitral valve prolapse

3. C

   Pulmonic stenosis

4. D

   Mitral regurgitation

Appeared in: GMCH Chandigarh - 2019

Explanation

• The combination of a mid-systolic click and a late systolic murmur heard at the apex is the hallmark of Mitral Valve Prolapse (MVP).
• The click is produced by the tensing of the redundant mitral valve leaflets and chordae tendineae as they prolapse into the left atrium during systole.
• The murmur becomes louder upon standing because this maneuver decreases venous return (preload), reducing the size of the left ventricle.
• A smaller ventricle causes the prolapse to occur earlier and more significantly, making the click appear earlier and the regurgitant murmur last longer and sound louder.

Why Other Options Were Wrong

• Option A: Aortic stenosis causes a crescendo-decrescendo systolic murmur at the right upper sternal border that radiates to the carotids. Critically, this murmur softens upon standing due to decreased preload, which is the opposite of the finding in the question.
• Option C: Pulmonic stenosis is characterized by a systolic ejection murmur heard best at the left upper sternal border (pulmonic area), not the apex. Its intensity often increases with inspiration.
• Option D: While located at the apex, the classic murmur of chronic mitral regurgitation is holosystolic (pansystolic), meaning it lasts throughout systole. The murmur described in the stem is mid-to-late systolic and is preceded by a click.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Auscultatory findings in valvular heart disease to guide bedside assessment, documentation, and the next nursing action.
• MVP is a common condition, particularly in young women, and is often benign. However, it can be associated with symptoms like palpitations, dizziness, fatigue, and anxiety.
• Nurses must be able to accurately identify and describe heart murmurs, including their timing, location, and response to maneuvers, to provide accurate information to the healthcare team.
• What if? If the murmur was holosystolic (pansystolic) at the apex and radiated to the axilla, the most likely diagnosis would shift from Mitral Valve Prolapse to chronic Mitral Regurgitation.

How to Approach the Question

• First, dissect the clinical findings provided in the question stem: identify the timing (mid-to-late systolic), character (click followed by a murmur), location (cardiac apex), and dynamic changes (louder on standing).
• Systematically review the classic auscultatory findings for each of the four valvular conditions listed in the options.
• The presence of a 'click' is a strong clue. Associate a mid-systolic click specifically with mitral valve prolapse.
• Focus on the effect of the maneuver. A murmur that gets louder on standing is unusual and is a classic feature of only two main conditions: Mitral Valve Prolapse and Hypertrophic Obstructive Cardiomyopathy (HOCM).
• Combine the findings: a mid-systolic click + late systolic murmur at the apex + intensification on standing points directly to Mitral Valve Prolapse.

Concept Tested & Keywords

• Concept Tested: Auscultatory findings in valvular heart disease
• Stem keywords: mid-to-late systolic click, mid-to-late systolic murmur, cardiac apex, murmur gets louder when she stands up, dizziness, easy fatigability
• Lead-in keywords: most likely
• Clinical cues: The patient is a young female, a common demographic for Mitral Valve Prolapse.
• Clinical cues: The murmur getting louder on standing is a key dynamic finding that strongly points away from most other murmurs and towards MVP or HOCM.

Question ID

QdlJ8lxCfPJrOEXb5kkrUs

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 1 pp. 1907-1909, 326-328

E6 Nelson Textbook of Pediatrics(2024) — Volume 2 p. 579-581