Week 4

Question 1

pectus carinatum

Answer 1

breastbone protrudes outward

Question 2

pectus excavatum

Answer 2

breastbone sunken into chest

Question 3

barrel chest

Answer 3

broad, deep chest

-seen with COPD

Question 4

SOB/ dyspnea

Answer 4

The degree of dyspnea, combined with spirometry, is a key component of important chronic obstructive pulmonary disease (COPD) classification systems that guide patient management.

Anxious patients may have episodic dyspnea during both rest and exercise and also hyperventilation, or rapid shallow breathing.

Question 5

wheezing

Answer 5

Wheezing occurs in partial lower airway obstruction from secretions and tissue inflammation in asthma, or from a foreign body.

Question 6

cough

Answer 6

These stimuli include mucus, pus, and blood as well as external agents such as allergens, dust, foreign bodies, and even extremely hot or cold air.

The most common cause of acute cough is viral upper respiratory infections. Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, and ACE-inhibitor therapy. Postinfectious cough, pertussis, acid reflux, bacterial sinusitis, and asthma can cause subacute cough. Chronic cough is seen in postnasal drip, asthma, gastroesophageal reflux, chronic bronchitis, and bronchiectasis.

Diagnostically helpful symptoms include fever and productive cough in pneumonia; wheezing in asthma; and chest pain, dyspnea, and orthopnea in acute coronary syndromes.

Question 7

productive cough

Answer 7

Mucoid sputum is translucent, white, or gray and seen in viral infections and cystic fibrosis; purulent sputum—yellow or green—often accompanies bacterial pneumonia.

Foul-smelling sputum is present in anaerobic lung abscess, thick tenacious sputum in cystic fibrosis.

Large volumes of purulent sputum are present in bronchiectasis and lung abscess

Question 8

hemoptysis

Answer 8

Causes include bronchitis; malignancy; cystic fibrosis; and, less commonly, bronchiectasis, mitral stenosis, Goodpasture syndrome, and granulomatosis with polyangiitis (formerly Wegener granulomatosis). Massive hemoptysis (>500 mL over a 24-hour period or ≥100 mL/hr) may be life-threatening.

Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles.

Question 9

myocardial- chest pain (possible causes)

Answer 9

Angina pectoris, myocardial infarction, myocarditis

Question 10

pericardial- chest pain (possible causes)

Answer 10

Pericarditis

Question 11

aortic- chest pain (possible causes)

Answer 11

Aortic dissection

Question 12

tracheal and large cronchial- chest pain (possible causes)

Answer 12

Bronchitis

Question 13

parietal pleural- chest pain (possible causes)

Answer 13

Pericarditis, pneumonia, pneumothorax, pleural effusion, pulmonary embolus, connective tissue disease

Question 14

Chest wall, including the skin, musculoskeletal and neurologic systems- chest pain (possible causes)

Answer 14

Costochondritis, herpes zoster

Question 15

esophageal- chest pain (possible causes)

Answer 15

Gastroesophageal reflux disease, esophageal spasm, esophageal tear

Question 16

Extrathoracic structures such as the neck, gallbladder, and stomach- chest pain (possible causes)

Answer 16

Cervical arthritis, biliary colic, gastritis

Question 17

chest pain- respiratory

Answer 17

Chest pain is reported in one in four patients with panic and anxiety disorders.

A clenched fist over the sternum (Levine sign) suggests angina pectoris; a finger pointing to a tender spot on the chest wall suggests musculoskeletal pain; a hand moving from the neck to the epigastrium may suggest heartburn.

Pain in conditions such as pneumonia and pulmonary infarction usually arises from inflammation of the adjacent parietal pleura. Muscle strain from prolonged recurrent coughing or costochondral inflammation may also be responsible. The pain of pericarditis stems from inflammation of the adjacent parietal pleura.

Question 18

daytime sleepiness, snoring, and disordered sleep

Answer 18

These symptoms, especially daytime sleepiness and snoring, are hallmarks of obstructive sleep apnea (OSA), commonly seen in patients with obesity, posterior malocclusion of the jaw (retrognathia), treatment-resistant hypertension, heart failure, atrial fibrillation, stroke, and type 2 diabetes. Mechanisms include instability of the brainstem respiratory center, disordered sleep arousal, disordered contraction of upper airway muscles (genioglossus malfunction), and anatomic changes contributing to airway collapse such as obesity, among others.

Question 19

chest pain- cardiovascular

Answer 19

Anterior chest pain, often tearing or ripping and radiating into the back or neck, occurs in acute aortic dissection.

Causes of chest pain in the absence of obstructive coronary artery disease on angiogram include microvascular coronary dysfunction and abnormal cardiac nocioception, which require specialized testing.12 Roughly half of women with chest pain and normal angiograms have microvascular coronary dysfunction.

Acute coronary syndrome is increasingly used to describe the clinical syndromes caused by acute myocardial ischemia, which include unstable angina, non—ST elevation MI, and ST elevation infarction.

Question 20

palpitations

Answer 20

Anxious and hyperthyroid patients may report palpitations.

The most serious dysrhythmias, such as ventricular tachycardia, often do not produce palpitations.

If there are symptoms or signs of irregular heart action, obtain an ECG. This includes atrial fibrillation, which causes an “irregularly irregular” pulse often identified at the bedside.

Clues in the history include transient skips and flip-flops (possible premature contractions); rapid regular beating of sudden onset and offset (possible paroxysmal supraventricular tachycardia); and a rapid regular rate of <120 beats/min, especially if gradually starting and stopping (possible sinus tachycardia).

Question 21

SOB- cardiovascular

Answer 21

Sudden dyspnea occurs in pulmonary embolus, spontaneous pneumothorax, and anxiety.

Orthopnea and PND occur in left ventricular heart failure and mitral stenosis and also in obstructive lung disease.

PND may be mimicked by nocturnal asthma attacks.

Question 22

edema

Answer 22

Causes are frequently cardiac (right or left ventricular dysfunction; pulmonary hypertension) or pulmonary (obstructive lung disease)20 but can also be nutritional (hypoalbuminemia), and/or positional. Dependent edema appears in the lowest body parts: the feet and lower legs when sitting, or the sacrum when bedridden. Anasarca is severe generalized edema extending to the sacrum and abdomen.

Look for the periorbital puffiness and tight rings of nephrotic syndrome and an enlarged waistline from ascites and liver failure.

Question 23

syncope

Answer 23

The more concerning causes of syncope involve the heart not providing adequate blood flow to the brain, as occurs in end-stage heart failure and arrhythmias.

Question 24

A group of students is reviewing information about the different types of murmurs. Which of the following would they identify as examples of midsystolic murmurs?

Answer 24

innocent

Question 25

What are the components of S1? (Select all that apply.)

a. later tricuspid sound
b. later pulmonic sound
c. earlier mitral sound
d. earlier tricuspid sound

Answer 25

a, c

Question 26

A nurse is evaluating a client’s jugular venous pressure. Which of the following findings would tend to indicate obstructive pulmonary disease?

Answer 26

Elevated venous pressure only during expiration

Question 27

A client who inhaled carbon monoxide (CO) presents in the trauma emergency center with headache, dizziness, weakness, chest pain, and confusion. What does the nurse recognize about the use of conventional pulse oximetry for this client?

Answer 27

Readings inaccurate due to CO-bound hemoglobin

Question 28

The nurse is caring for an adult client who has acute bronchitis. What is the most probable cause of this condition?

Answer 28

virus

Question 29

A 24-year-old man is rushed to the emergency room following an injury sustained in a motor vehicle accident. He complains of breathing difficulty and right-sided chest pain, which he describes as 8/10, sharp in character, and worse with deep inspiration. His vitals are: blood pressure 90/65 mm Hg; respiratory rate 30/min; pulse 120/min; and temperature 37.2°C (99.0°F). The patient is alert and oriented but in severe distress due to multiple bruises over the anterior chest wall and significant jugular venous distention as well as subcutaneous emphysema at the base of the neck. There is also absence of breath sounds on the right and hyper-resonance to percussion. A bedside chest radiograph shows evidence of a collapsed right lung with a depressed right hemidiaphragm and tracheal deviation to the left. Which of the following findings is the strongest indicator of cardiogenic shock in this patient?

Answer 29

JVD

Question 30

A 31-year-old woman presents to the clinic with shortness of breath, palpitations, and fatigue. She has had these symptoms over the last several weeks. She had been tolerating these symptoms until last night when she could not fall asleep due to palpitations. She has a past medical history of infective endocarditis 6 months ago that was successfully treated with antibiotics. She does not smoke or drink alcohol. Her blood pressure is 138/89 mm Hg and her pulse is 76/min and regular. The cardiac exam reveals a soft S1, S3 gallop, a hyperdynamic apex beat, and a pansystolic murmur that radiates to the axilla on auscultation. Echocardiography reveals incompetence of one of the valves. Which of the following sites is the best position to auscultate this defect?

Answer 30

5th intercostal space at the midclavicular line on the left side

Question 31

A 55-year-old woman is brought to the emergency department due to a sudden onset of retrosternal chest pain. An ECG shows ST-segment elevation. A diagnosis of myocardial infarction is made and later confirmed by elevated levels of troponin I. She is sent to the cardiac catheter laboratory to undergo percutaneous catheterization. She is found to have 2 occluded coronary vessels and stents are implanted to restore blood flow in the affected arteries. She complains of flank pain during post-procedure evaluation a few hours later. A significant drop in hematocrit is observed, as well as a decline in her blood pressure to 90/60 mm Hg. Physical exam reveals extensive ecchymoses in the flanks and loin as shown in the image. Which of the following conditions is this patient most likely experiencing?

Answer 31

Complication from femoral artery access

Question 32

Which statements are true concerning the location and structure of the trachea and major bronchi?

Answer 32

The trachea divides or bifurcates anteriorly at the sternal angle.

Question 33

The nurse notes that client’s breathing pattern is regular but has periods of deep, rapid breathing followed by periods of apnea. What should the nurse consider as causing this client’s breathing patterns? Select all that apply.

a. renal failure
b. increased ICP
c. diabetic ketoacidosis
d. severe CHF
e. drug overdose

Answer 33

a, b, d, e

Question 34

Which accessory muscles are most important when considering inspiratory breathing needs during exercise?

Answer 34

SCMs

Question 35

During a health history of the respiratory system, a client reports experiencing a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? (Select all that apply.)

a. “Do you cough up mucus or phlegm?”
b. “Does it occur at rest or with exercise?
c. “Is it continuous or intermittent?”
d. “Does this occur at a particular time of day?”
e. “Does it wake you at night?”

Answer 35

b, c, d, e

Question 36

During a physical assessment, the nurse identifies unequal chest expansion. The nurse knows this could be due to what? Select all that apply.

a. trauma
b. pneumonia
c. atelactasis
d. pneumothorax
e. emphysema

Answer 36

a, b, c, d

Question 37

The nurse notes that a client has decreased fremitus in the left upper lung lobe. What should the nurse consider as causing this assessment finding? Select all that apply.

a. pleural effusion
b. pneumonia
c. bronchial obstruction
d. asthma
e. pneumothorax

Answer 37

a, c, e

Question 38

A client is coughing copious amounts of purulent mucous. What disease condition is related to this finding?

Answer 38

lung abscess

Question 39

A client reports to the NP that he experiences fatigue during the day, has difficulty sleeping lying down, and often wakes up at night feeling short of breath. The NP should assess this client for other findings related to what disease process?

Answer 39

HF

Question 40

A nurse is interviewing a client who complains of dyspnea. Which of the following findings would tend to indicate an underlying cardiovascular problem in the client? Select all that apply.

a. angina
b. coughing that produces white sputum
c. snoring and gasping while sleeping
d. edema
e. coughing occurring at night
f. orthopnea

Answer 40

a, d, f

Question 41

A client complains of shortness of breath for the past few days. Examination reveals late inspiratory crackles in the lower third of the chest that were not present 1 week ago. What is the most likely explanation?

Answer 41

HF

Question 42

Which abnormal respiratory finding should the nurse expect to observe upon assessment of a client with a pleural effusion?

Answer 42

Dyspnea on exertion and dry, nonproductive cough

Question 43

An adult client has been diagnosed with bronchitis. What would the nurse most likely hear on auscultation?

Answer 43

sonorous wheezes

Question 44

A client comes to the clinic complaining of waking during the night with sudden shortness of breath. She is diagnosed with paroxysmal nocturnal dyspnea. Before leaving the clinic, the client asks the nurse what causes paroxysmal nocturnal dyspnea. What would be the nurse’s best response?

Answer 44

Fluid overload from elevation of the legs

Question 45

Which characteristic of the apical pulse should a nurse expect to find in the client diagnosed with left ventricular hypertrophy?

Answer 45

displaced

Question 46

A NP auscultates the heart of a client with hypertension for the past ten (10) years. With the client in the left lateral position, the NP hears a heart sound that occurs just before S1. The NP recognizes this sound as what pathological process?

Answer 46

Atrial contractions heard as vibrations against stiff walled ventricles

Question 47

The S4 heart sound

Answer 47

can be heard during diastole

Question 48

The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that paradoxical pulses are usually indicative of

Answer 48

obstructive lung disease

Question 49

The client is known to have a bundle branch block that delays activation of the right ventricle as a result of a recent myocardial infarction (MI). What would the nurse expect to hear when auscultating the client’s heart sounds?

Answer 49

wide splitting

Question 50

A nurse assesses a client’s jugular venous pulse to gather information about which of the following?

Answer 50

hemodynamics of right side of heart

Question 51

A client is admitted for the new onset of heart failure. The nurse recognizes that which finding is the earliest sign of heart failure?

Answer 51

Auscultation of an S3 heart sound

Question 52

During the auscultation of a client’s heart sounds, the nurse hears a fixed S2 split. What does this heart sound indicate to the nurse?

Answer 52

right ventricular failure

Question 53

A NP cares for a client with acute pericarditis. The NP should monitor the client for the onset of which clinical manifestation of cardiac tamponade?

Answer 53

paradoxical pulse

Question 54

The nurse hears a murmur in a client with a known mitral valve prolapse. The murmur most likely occurs in

Answer 54

late systole

Question 55

The nurse’s auscultation of a 22-year-old client’s apical heart rate reveals the presence of S3. When the client stands upright, the S3 is no longer audible. How should the nurse respond to this assessment finding?

Answer 55

Recognize this as a normal assessment finding in this client.

Question 56

While auscultating heart sounds, asking the client to turn onto a left lying position would help the nurse assess the presence of which of the following?

Answer 56

mitral stenosis

Question 57

Suzanne is a 20-year-old college student who complains of chest pain. The pain is intermittent and located to the left of her sternum. There are no associated symptoms. Examination reveals a short, high-pitched sound in systole, followed by a murmur that increases in intensity until S2. It is heard best over the apex. When she squats, this noise moves later in systole along with the murmur. Which of the following is the most likely diagnosis?

Answer 57

mitral valve prolapse

Question 58

A nurse expects to find which abnormal heart sound in a client diagnosed with mitral valve prolapse?

Answer 58

midsystolic click

Question 59

Vasovagal Syncope (Common Faint) and Vasodepressor Syncope

Answer 59

mechanism:
- For vasovagal syncope: reflex withdrawal of sympathetic tone and increased vagal tone causing drop in blood pressure and heart rate
- For vasodepressor syncope: same mechanism but no vagal surge or drop in heart rate
- Baroreflexes normal

precipitating factors:
-Strong emotion such as fear or pain, prolonged standing, hot humid environment

predisposing factors:
-Fatigue, hunger, preload reduction from dehydration, diuretics, vasodilators

prodromal manifestations:
-Usually >10 s; palpitations, nausea, blurred vision, warmth, pallor, diaphoresis, lightheadedness

postural associations:
-Usually occurs when standing, at times when sitting

recovery:
-Prompt return of consciousness after lying down, but pallor, weakness, nausea, and slight confusion may persist for a time; most common type of syncope

Question 60

orthostatic hypotension (1)

Answer 60

mechanism: Gravitationally mediated redistribution and pooling of 300–800 mL blood in the lower extremities and splanchnic venous system, caused by decreased venous return and an excessive fall in cardiac output, or by an inadequate vasoconstrictor mechanism (with inadequate release of norepinephrine)

precipitating factors: Standing up

predisposing factors: Aging; antihypertensive vasodilator drugs; prolonged bed rest central disorders: Parkinson disease, multiple system atrophy; dementia with Lewy bodies; peripheral neuropathy: diabetes, amyloidosis

prodromal manifestations: Lightheadedness, dizziness, cognitive slowing, fatigue; often none

postural associations:

• Occurs soon after standing
• Supine hypertension is common

recovery: Prompt return to normal when lying down

Question 61

orthostatic hypotension (2)

Answer 61

mechanism: Hypovolemia, a diminished blood volume insufficient to maintain cardiac output and blood pressure

precipitating factors: Standing up after hemorrhage or dehydration

predisposing factors: Bleeding from the GI tract or trauma, potent diuretics, vomiting, diarrhea, polyuria

prodromal manifestations: Lightheadedness and palpitations (tachycardia) on standing up

postural associations: Occurs soon after standing up

recovery: Improves with volume repletion

Question 62

cough syncope

Answer 62

mech: Neurally mediated, possibly from reflex vasodepressor–bradycardia response; cerebral hypoperfusion, increased CSF pressure also proposed

proliferating factors: Severe paroxysm of coughing

predisposing factors: COPD, asthma, pulmonary hypertension; typically occurs in overweight middle-aged patients

prodromal manifestations: Often none except for cough; blurred vision, lightheadedness may occur

postural associations: May occur in any position

recovery: Prompt return to normal after a few seconds

Question 63

micturition syncope

Answer 63

mech: Vasovagal response, sudden hypotension proposed

proliferating factors: Emptying the bladder after getting out of bed to void

predisposing factors: Nocturia, usually in elderly or adult men

prodromal factors: often none

postural associations: Commonly just after (or during) voiding after standing up

recovery: Prompt return to normal

Question 64

arrhythmias

Answer 64

mech: Decreased cardiac output from cardiac ischemia, ventricular arrhythmias, prolonged QT syndrome, persistent bradycardia, infrafascicular block causing cerebral hypoperfusion; often sudden onset, sudden offset

precipitating factors: Sudden change in rhythm to bradycardia or tachyarrhythmia

predisposing factors: Ischemic or valvular heart disease, conduction abnormalities, pericardial disease, cardiomyopathy; aging decreases tolerance of abnormal rhythms

proliferating factors: Palpitations, usually lasting <5 s; often none

postural association: May occur in any position

recovery: Prompt return to normal when arrhythmia resolves; most common cause of cardiac syncope; cardiogenic syncope has a 6-mo mortality >10%

Question 65

Aortic Stenosis and Hypertrophic Cardiomyopathy

Answer 65

mech: Vascular resistance falls with exercise, but cardiac output does not rise due to outflow obstruction

precipitating factors: exercise

proliferating factors: cardiac disorders

predisposing factors: Chest pain, often none; onset is sudden

postural association: Occurs with or after exercise

recovery: Usually a prompt return to normal

Question 66

Myocardial Infarction

Answer 66

mech: Sudden arrhythmia or decreased cardiac output

precipitating factors: Variable, often exertion

proliferating factors: Coronary artery disease, coronary ischemia or vasospasm

predisposing factors: Ischemic chest pain; may be silent

postural association: May occur in any position

recovery: Variable; related to time to diagnosis and treatment

Question 67

Massive Pulmonary Embolism

Answer 67

mech: Sudden hypoxia or decreased cardiac output

precipitating factors: Variable, including prolonged bed rest, major surgery, clotting disorders, pregnancy

proliferating factors: Deep vein thrombosis, bed rest, hypercoagulable states (systemic lupus erythematosus, cancer), protein S or C deficiency antithrombin III deficiency; estrogen therapy

predisposing factors: Tachypnea, chest or pleuritic pain, dyspnea, anxiety, cough

postural association: May occur in any position

recovery: Related to time to diagnosis and treatment

Question 68

Hypocapnia due to Hyperventilation

Answer 68

mech: Constriction of cerebral blood vessels from hypocapnia induced by hyperventilation

precipitating factors: Anxiety, panic disorder

proliferating factors: Anxiety

predisposing factors: Dyspnea, palpitations, chest discomfort, numbness, and tingling in hands and around the mouth lasting several minutes; consciousness is often maintained

postural association: May occur in any position

recovery: Slow improvement as hyperventilation ceases

Question 69

Hypoglycemia

Answer 69

mech: Insufficient glucose to maintain cerebral metabolism; epinephrine release contributes to symptoms; true syncope is uncommon

precipitating factors: Variable, including fasting

proliferating factors: Insulin therapy and a variety of metabolic disorders

predisposing factors: Sweating, tremors, palpitations, hunger, headache, confusion, abnormal behavior, coma

postural association: May occur in any position

recovery: Variable, depending on severity and treatment

Question 70

Fainting from Conversion Disorder

Termed “Functional Neurologic Symptom Disorder” in DSM-5

Answer 70

mech: unknown; Skin color, vital signs may be normal; sometimes with bizarre purposeful movements; usually occurs when other people present

precipitating factors: Stress or trauma, psychological or physical Sometimes no precipitant identified

predisposing factors:

• History of multiple somatic symptoms
• Often dissociative symptoms such as depersonalization, derealization, dissociative amnesia, or maladaptive personality traits; associated with past child abuse or neglect

prodromal factors: variable

recovery: A slump to the floor, often from a standing position, without injury

Question 71

What is the most common kind of heart murmur?

Answer 71

Midsystolic ejection murmurs are the most common kind of heart murmur.

They may be

(1) innocent—without any detectable physiologic or structural abnormality;
(2) physiologic—from physiologic changes in body metabolism; or
(3) pathologic—arising from structural abnormalities in the heart or great vessels.

Question 72

innocent murmurs

Answer 72

Location. Left second to fourth intercostal spaces between the left sternal border and the apex

Radiation. Minimal

Intensity. Grades 1 to 2, possibly 3

Pitch. Soft to medium

Quality. Variable

Maneuvers. Usually decreases or disappears on sitting

Association Findings- None: normal splitting, no ejection sounds, no diastolic murmurs, and no palpable evidence of ventricular enlargement. Occasionally, both an innocent murmur and pathologic murmur are present.

Mech- Turbulent blood flow, probably generated by ventricular ejection of blood into the aorta from the left and occasionally the right ventricle. Very common in children and young adults but may also be present in older adults. There is no underlying CVD.

Question 73

physiologi murmurs

Answer 73

similar to innocent murmurs

Associated Findings- Signs of physiologic causes (see mechanisms below)

Mech- Turbulence due to a temporary increase in blood flow in predisposing conditions such as anemia, pregnancy, fever, and hyperthyroidism.

Question 74

aortic stenosis

Answer 74

Location. Right second and third intercostal spaces

Radiation. Often to the carotids, down the left sternal border, even to the apex. If severe, may radiate to left second and third intercostal spaces

Intensity. Sometimes soft, but often loud, with a thrill

Pitch. Medium, harsh; crescendo–decrescendo may be higher at the apex

Quality. Often harsh; may be more musical at the apex

Maneuvers. Heard best with the patient sitting and leaning forward

Associated Findings- As aortic stenosis worsens, the murmur peaks later in systole, and A2 decreases in intensity. A2 may be delayed and merged with P2 → single S2 on expiration or a paradoxical S2 split. Carotid upstroke may be delayed, with a slow rise, small amplitude, and decreased volume. The hypertrophied left ventricle may produce a sustained apical impulse and an S4 due to decreased compliance. After age 40 years there may be a dilated aorta and murmur of aortic regurgitation. Subendocardial ischemia due to poor coronary perfusion distal to the valve causes angina and syncope.

Mech- Significant stenosis causes turbulent blood flow across the valve and increases left ventricular afterload. The most common cause is valve calcification in older adults, at times progressing from nonobstructing sclerosis (present in 25%) to stenosis. The second most common cause is a congenital bicuspid aortic valve, often not recognized until adulthood.

Question 75

hypertrophic cardiomyopathy

Answer 75

Location. Left third and fourth intercostal spaces

Radiation. Down the left sternal border to the apex, possibly to the base, but not to the neck

Intensity. Variable. See Maneuvers.

Pitch. Medium

Quality. Harsh

Maneuvers. Intensity decreases with squatting and Valsalva release phase (increases venous return), increases with standing and Valsalva strain phase (decreases left ventricular volume) (see p. 528)

Associated Findings

• The carotid upstroke rises quickly, unlike aortic stenosis. The apical impulse is sustained. S2 may be single. An S4 is usually present at the apex (unlike mitral regurgitation).
• Usually benign, but progresses in 25% to syncope, ischemia, atrial fibrillation, dilated cardiomyopathy and heart failure, and stroke, with increased risk of sudden death.

Mech- Unexplained diffuse or focal ventricular hypertrophy with myocyte disarray and fibrosis associated with unusually rapid ejection of blood from the left ventricle during systole. Outflow tract obstruction of flow may coexist. Associated distortion of the mitral valve may cause mitral regurgitation.

Question 76

pulmonic stenosis

Answer 76

Location. Left second and third intercostal spaces

Radiation. If loud, toward the left shoulder and neck

Intensity. Soft to loud; if loud, associated with a thrill

Pitch. Medium; crescendo–decrescendo

Quality. Often harsh

Associated Findings- The JVP is usually normal but may have prominent a wave. The right ventricular impulse is often sustained. An early pulmonic ejection sound is present in mild to moderate stenosis. In severe stenosis, S2 is widely split and P2 softens. May hear a right-sided S4 over the left sternal border.

Mech- Primarily a congenital disorder with valvular, supravalvular, or subvalvular stenosis. Stenosis impairs flow across the valve, increasing right ventricular afterload. In an atrial septal defect, increased flow across the pulmonic valve may mimic pulmonic stenosis.

Question 77

mitral regurgitation

Answer 77

Location. Apex

Radiation. To the left axilla, less often to the left sternal border

Intensity. Soft to loud; if loud, associated with an apical thrill

Pitch. Medium to high

Quality. Blowing, holosystolic

Maneuvers. Unlike tricuspid regurgitation, the intensity of the murmur does not change with inspiration.

Associated Findings-

• S1 normal (75%), loud (12%), soft (12%)
• An apical S3 reflects volume overload of the left ventricle.
• The apical impulse may be diffuse and laterally displaced. There may be a sustained lower left parasternal impulse from a dilated left atrium.

Mech- When the mitral valve fails to close fully in systole, blood regurgitates from left ventricle to left atrium, causing the murmur and increasing left ventricular preload, ultimately leading to left ventricular dilatation. Causes are structural, from mitral valve prolapse, infectious endocarditis, rheumatic heart disease, and collagen vascular disease; and functional, from ventricular dilatation and dilatation of the mitral valve annulus and from leaflet, papillary muscle, or chordae tendineae dysfunction.

Question 78

tricuspid regurgitation

Answer 78

Location. Lower left sternal border. If right ventricular pressure is high and the ventricle is enlarged, the murmur may be loudest at the apex and confused with mitral regurgitation.

Radiation. To the right of the sternum, to the xiphoid area, and at times to the left midclavicular line, but not into the axilla.

Intensity. Variable

Pitch. Medium

Quality. Blowing, holosystolic

Maneuvers. Unlike mitral regurgitation, the intensity increases with inspiration.

Associated Findings

• The right ventricular impulse is increased in amplitude and may be sustained.
• The JVP is often elevated in severe tricuspid regurgitation, with large v waves in the jugular veins, a pulsatile liver, ascites, and edema.

Mech
-When the tricuspid valve fails to close fully in systole, blood regurgitates from RV to right atrium, producing a murmur. The most common causes are: right ventricular failure and dilatation, with resulting enlargement of the tricuspid orifice, often induced by pulmonary hypertension or left ventricular failure; and endocarditis—the RV and pulmonary artery pressures are low, so the murmur is early systolic.

Question 79

ventricular septal defect

Answer 79

Location. Left third, fourth, and fifth intercostal spaces

Radiation. Often wide, depending on the size of the defect.

Intensity. Often very loud, with a thrill. Smaller defects have louder murmurs.

Pitch. High, holosystolic. Smaller defects have murmurs with a higher pitch.

Quality. Often harsh

Associated Findings

• S2 may be obscured by the loud murmur.
• Findings and associated findings vary with the size of the defect. Larger defects cause left-to-right shunts, pulmonary hypertension, and right ventricular overload.

Mech
-A ventricular septal defect is a congenital abnormality classified according to one of four locations in the ventricular septum. The defect is a conduit for blood flow from the relatively high-pressure left ventricle into the low-pressure right ventricle. The defect may be accompanied by aortic regurgitation, tricuspid regurgitation, and aneurysms of the ventricular septum; an uncomplicated lesion is described here.

Question 80

aortic regurgitation

Answer 80

Location. Left second to fourth intercostal spaces

Radiation. If loud, to the apex, perhaps to the right sternal border

Intensity. Grades 1 to 4

Pitch. High. Use the diaphragm.

Quality. Blowing decrescendo; may be mistaken for breath sounds

Maneuvers. The murmur is heard best with the patient sitting, leaning forward, with breath held after exhalation.

Associated Findings

• With advancing severity, the diastolic pressure drops to as low as 50 mm Hg; the pulse pressure can widen by >80 mm Hg.
• The apical impulse becomes diffuse, displaced laterally and downward, and increased in diameter, amplitude, and duration. A systolic ejection sound may be present; S2 is increased in aortic root dilatation and decreased if leaflets are thickened and calcified; and an S3 often reflects ventricular dysfunction from both volume and pressure overload. A midsystolic flow murmur or a mitral diastolic (Austin Flint) murmur, usually with middiastolic and presystolic components, reflect increased regurgitant flow.
• The arterial pulse wave collapses suddenly creating bounding arterial pulses with pistol shot sounds on light pressure of the diaphragm, especially with arm elevation (Corrigan pulse), a to–fro murmur over the brachial or femoral artery with firm pressure (Duroziez sign), and capillary pulsations with nail blanching (Quincke pulses).

Mech
-The aortic valve leaflets fail to close completely during diastole, causing regurgitation from the aorta back into the left ventricle and left ventricular overload. The associated midsystolic flow murmur results from the ejection of this increased stroke volume across the aortic valve. The mitral diastolic (Austin Flint) murmur is seen in moderate to severe disease and attributed to diastolic impingement of the regurgitant flow on the anterior leaflet of the mitral valve. Causes include leaflet abnormalities, aortic pathology (Marfan syndrome), and subvalvular abnormalities such as subaortic stenosis or an atrial septal defect.

Question 81

mitral stenosis

Answer 81

Location. Usually limited to the apex

Radiation. Little or none

Pitch. Decrescendo low-pitched rumble with presystolic accentuation. Use the bell.

Maneuvers. Placing the bell exactly on the apical impulse, turning the patient into a left lateral position, and mild exercise like handgrips make the murmur audible. It is heard better in exhalation.

Associated Findings

• S1 is loud and may be palpable at the apex. An OS often follows S2 and initiates the murmur.
• If pulmonary hypertension develops, P2 is accentuated, the right ventricular parasternal impulse becomes palpable, and the a wave of the JVP is more prominent. The apical impulse is small and tapping.
• Atrial fibrillation occurs in about a third of symptomatic patients, with ensuing risks of thromboembolism.

Mech
-The stiffened mitral valve leaflets move into the left atrium in midsystole and narrow the valve opening, causing turbulence. The resulting murmur has two components: (1) middiastolic (during rapid ventricular filling) and (2) presystolic accentuation, possibly related to ventricular contraction. The most common cause worldwide is rheumatic fever, which causes fibrosis, calcification, and thickening of the leaflets and commissures, and chordal fusion.