Match each patient's clinical presentation and dynamic auscultation findings to the most likely underlying structural or valvular pathology.
- A 22-year-old athlete presents with a harsh crescendo-decrescendo systolic murmur at the left lower sternal border that increases in intensity when transitioning from squatting to a standing position.Severe left ventricular outflow tract obstruction due to asymmetric septal hypertrophy
- A 75-year-old man presents with a harsh crescendo-decrescendo systolic murmur at the right upper sternal border. The murmur decreases in intensity during the strain phase of the Valsalva maneuver.Age-related calcific degeneration of the aortic valve leaflets
- A 45-year-old woman presents with a late systolic murmur preceded by a mid-systolic click at the apex. The click occurs earlier in systole when she stands up from a sitting position.Myxomatous degeneration of the mitral valve leaflets
- A 60-year-old man presents with a high-pitched, blowing, early diastolic decrescendo murmur at the left sternal border that becomes louder with sustained isometric handgrip.Dilation of the aortic root leading to poor leaflet coaptation
- A 65-year-old woman with a history of myocardial infarction presents with a blowing holosystolic murmur at the apex that radiates to the axilla and becomes louder with sustained isometric handgrip.Ischemic dysfunction of the papillary muscle causing incomplete leaflet closure
Answer
The presentations map as follows: the athlete with a louder murmur on standing has hypertrophic cardiomyopathy; the older man with a softer murmur on Valsalva has calcific aortic stenosis; the woman with an earlier click on standing has mitral valve prolapse; the man with a louder diastolic murmur on handgrip has aortic regurgitation; and the woman with a louder holosystolic murmur on handgrip has mitral regurgitation.
Each pairing correctly applies the principles of dynamic auscultation. Maneuvers that decrease preload (Valsalva strain, standing) soften most murmurs due to reduced transvalvular flow. The notable exceptions are hypertrophic cardiomyopathy (murmur becomes louder due to increased obstruction) and mitral valve prolapse (click occurs earlier and murmur lengthens). Maneuvers that increase afterload (handgrip) increase regurgitant murmurs like AR and MR by raising the pressure gradient driving backward flow, but decrease forward-flow murmurs like AS and HCM.
Step-by-Step Solution
Key Concept
Dynamic auscultation and structural heart disease