1. With which abnormality do you often find a mid-systolic dip in the presence of LVH?
ANS: Hypertrophic obstructive cardiomyopathy (HOCM).
2. What kind of impulse may be imparted to the apex beat of a patient with severe HOCM if an A wave is also present?
ANS: A triple outward movement (known by some as a "triple ripple"). This is almost pathognomonic of HOCM).
3. Which valvular abnormality may have a mid-systolic dip without LVH?
ANS: A prolapsed mitral valve. An S4 or a click and murmur quickly differentiates the cause of the dip.
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