A lady presented with dyspnea and palpitations. On examination there was a non ejection click. Next investigation is: March 2009

Okay, let's tackle this question. The patient has dyspnea and palpitations with a non-ejection click. Hmm, non-ejection click... I remember that's a high-pitched sound heard in mitral valve prolapse. Mitral valve prolapse can cause MVP, which might lead to mitral regurgitation. The next step would probably be an echocardiogram to confirm the diagnosis. Wait, but what other tests could it be? Maybe an ECG? But ECG might not show the structural issue. Chest X-ray? Maybe, but not specific. Stress test? Not first line. So the best answer is echocardiogram. Let me check the options again. The correct answer is likely B. Echocardiogram. The non-ejection click is key here. The other options like CXR or ECG are less specific. So the clinical pearl is to associate non-ejection click with MVP and order echo.

**Core Concept**
The non-ejection click is a hallmark auscultatory finding in **mitral valve prolapse (MVP)**, caused by sudden tensing of the mitral chordae tendineae during systole. This condition often leads to **mitral regurgitation**, which explains symptoms like dyspnea and palpitations. Confirming the diagnosis requires imaging of the mitral valve.

**Why the Correct Answer is Right**
**Echocardiography** is the gold standard for diagnosing mitral valve abnormalities. It visualizes the **prolapsed mitral leaflet**, assesses regurgitation severity, and evaluates left ventricular function. The non-ejection click’s timing (mid-systolic) and association with MVP make echocardiography the next logical step, as it directly confirms the structural pathology.

**Why Each Wrong Option is Incorrect**
**Option A: Chest X-ray** – May show cardiomegaly or pulmonary congestion but lacks specificity for valvular pathology.
**Option C: Electrocardiogram (ECG)** – Detects arrhythmias or ischemia but not structural valve defects.
**Option D: Stress test** – Indicated for ischemic heart disease, not for diagnosing MVP or regurgitation.

**Clinical Pearl / High-Yield Fact**
Remember the **"click-murmur" sequence** in MVP: a **non-ejection click** (prolapse) followed by a **holosystolic murmur** (regurgitation). Always order **echo** when this auscultatory finding is present. Avoid relying solely on symptoms or nonspecific tests like CXR or ECG.

**Correct Answer: B. Echocardiography**

✓ Correct Answer: D. Echocardiography