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Chapter 11: The History, Physical Examination, and Cardiac Auscultation

All of the following findings would suggest a diagnosis of hypertrophic cardiomyopathy except:

A. Paradoxically split S2

B. Bifid pulse

C. “Triple ripple” apical impulse

D. S4

E. Fixed split S2

The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 11). Fixed splitting of S2 is classically found in ostium secundum atrial septal defect, where wide splitting of S2 is present at baseline with minimal or no change in the A2-P2 interval during inspiration. Conversely, paradoxical splitting of the S2 is more common in obstructive hypertrophic cardiomyopathy, suggesting severe dynamic left ventricular outflow obstruction. Hypertrophic cardiomyopathy with obstruction is a cause of a bifid pulse, caused by the occurrence of obstruction starting in midsystole. This is seen as a spike-and-dome pattern on aortic pressure tracing. Patients with HOCM might also have a classic apical impulse—the so-called triple ripple—corresponding to the presence of palpable systolic impulse in early and midsystole, separated by withdrawal of the apical impulse related to dynamic outflow obstruction; a palpable atrial contraction corresponds to the third impulse. An S4 is often heard in patients with abnormalities of ventricular relaxation, such as hypertropic cardiomyopathy.

A 35-year-old man with a history of intravenous drug abuse and known bicuspid aortic valve presents with increasing shortness of breath, fevers, and lethargy. All of the following physical examination findings would suggest a diagnosis of aortic insufficiency complicating infective endocarditis except:

A. Bisferiens pulse

B. A high-pitched, “cooing,” diastolic murmur

C. A middiastolic rumble

D. Diastolic murmur best heard over the second right intercostal space

E. Arterial pulse that is increased in amplitude

The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 11). Aortic regurgitation murmurs heard over the second right intercostal space result from annular dilatation, whereas murmurs heard over the third left intercostal space result from a valvular process. When mixed aortic valve disease is present and the aortic regurgitation is the predominant lesion, an arterial contour with increased amplitude and two palpable systolic peaks can be present—the bisferiens pulse (option A is incorrect). The murmur of aortic regurgitation is a high-pitched “cooing” sound resulting from the high pressure difference between the aorta and left ventricular pressures during diastole (option B is incorrect). A middiastolic rumble, the Austin-Flint murmur, may be heard in aortic regurgitation when an eccentric jet hits the anterior leaflet of the mitral valve, causing ...

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