Nice little table for you to take a look at
all the different maneuvers. I am just going
to show you one little point for each of these
lines and on your own time make sure that you
are clear about how to interpret this. If
you understood everything I said, this table
becomes absolutely invaluable. Lying down,
tell me about venous return. Increased.
It is going to increase the murmur of every single
murmur except for HOCM and tell me about MVP.
The click is delayed, the murmur is decreased.
Next, sudden standing, where is my blood?
Down in the legs so, therefore, decreased venous
return. So, therefore, tell me about HOCM.
The outflow tract gets worse, increased intensity.
What about MVP? When there is decreased amount
of blood, the click gets closer to S1, early click
long lengthen murmur. Let us move on. Squatting,
increased venous return. You see the point
now. You take a look at squatting and lying down,
pretty similar. Valsalva, take a look at valsalva
in standing up. Pretty similar. Post PVC beat,
so this is a little bit more detail in
terms of your premature ventricular type of
issue. With handgrip you are going to increase the
afterload, there is more blood that is going
to be left inside my heart. Now be careful
here. With stenosis of aortic and pulmonic
with handgrip is about the pressure gradient
and, therefore, the intensity of murmur is
going to decrease. In HOCM, handgrip, more blood
in my heart. So, therefore, more seperation
of the outflow tract. MR, MS, and AR in those
cases you are then going to increase the intensity
of murmur, especially MR and AR. Amyl nitrate,
now where is my blood? With amyl nitrate,
what ends up happening is that you have decreased
preload because you have decreased venous
return. Think of nitrate as causing decreased
preload due to venodilation. So, therefore,
there is more pooling of your blood in your
veins. Not at your heart, the veins. So if
you have more blood in your veins, less in
your heart, what then happens to hypertrophic
obstructive cardiomyopathy? The obstruction
well, it gets worsened. Increased intensity,
clear? So these are things that you are paying
attention to as you are going through the
various maneuvers. You want to try to get
a good idea of at least some of the ones that
I just mentioned here for sure and anything
beyond that. Well, you take a look at on your
own time and you do this ever so often. You
do this reinforcement and before you know it,
the stuff is coming to you like its instinct.