American College of Physicians: Internal Medicine — Doctors for Adults ®


The MKSAP Challenge

From the September ACP Observer, copyright 2005 by the American College of Physicians.

Clinical scenario

A 37-year-old man is evaluated in the office for a first episode of syncope. The event was brief and occurred while he was engaged in light activity. On physical examination, his blood pressure is 110/68 mm Hg, his pulse rate is 70/min and his respiration rate is 12/min. The cardiac apex is displaced laterally. The first and second heart sounds are normal. There is a grade 2/6 midsystolic murmur heard at the left sternal border that decreases when the patient is asked to squat; it increases during a Valsalva maneuver. The murmur does not radiate into the carotid arteries and does not change with respiration.

Which of the following is the most likely diagnosis?

A. Aortic stenosis
B. Atrial septal defect
C. Hypertrophic cardiomyopathy
D. Mitral regurgitation
E. Primary pulmonary hypertension



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