During cardiac auscultation, I have the patient lean forward, take a deep breath, and forcefully exhale. The combination of maneuvers causes retractions of the chest cavity, making the heart closer to the anterior chest wall. This pseudo-Valsalva maneuver also puts strain on the heart valves, bringing out any valve murmur. I call it the “Mullen maneuver.”
—James P. Mullen, MD, Spokane, Wash.
—Susan Kashaf, MD, MPH (99-20)