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