- You are performing a thorough cardiac examination. Which of the following chambers of the heart can you assess by palpation?
A) Left atrium
B) Right atrium
C) Right ventricle
D) Sinus node
Ans: C
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Page and Header: 323, Anatomy and Physiology
Feedback: The right ventricle occupies most of the anterior cardiac surface and is easily accessible to palpation. The other structures are less likely to have findings on palpation and the sinus node is an intracardiac structure. You may be able to diagnose abnormal rhythms caused by the sinus node indirectly by palpation, but this is less obvious.
- What is responsible for the inspiratory splitting of S2?
A) Closure of aortic, then pulmonic valves
B) Closure of mitral, then tricuspid valves
C) Closure of aortic, then tricuspid valves
D) Closure of mitral, then pulmonic valves
Ans: A
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Page and Header: 323, Anatomy and Physiology
Feedback: During inspiration, the closure of the aortic valve and the closure of the pulmonic valve separate slightly, and this may be heard as two audible components, instead of a single sound. Current explanations of inspiratory splitting include increased capacitance in the pulmonary vascular bed during inspiration, which prolongs ejection of blood from the right ventricle, delaying closure of the pulmonic valve. Because the pulmonic component is soft, you may not hear it away from the left second intercostal space. Because it is a low-pitched sound, you may not hear it unless you use the bell of your stethoscope. It is generally easy to hear in school-aged children, and it is easy to notice the respiratory variation of the splitting.
- A 25-year-old optical technician comes to your clinic for evaluation of fatigue. As part of your physical examination, you listen to her heart and hear a murmur only at the cardiac apex. Which valve is most likely to be involved, based on the location of the murmur?
A) Mitral
B) Tricuspid
C) Aortic
D) Pulmonic
Ans: A
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Feedback: Mitral valve sounds are usually heard best at and around the cardiac apex.
- A 58-year-old teacher presents to your clinic with a complaint of breathlessness with activity. The patient has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems?
A) Abdominal pain
B) Orthopnea
C) Hematochezia
D) Tenesmus
Ans: B
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Feedback: Orthopnea, which is dyspnea that occurs when the patient is lying down and improves when the patient sits up, is part of the cardiovascular review of systems and, if positive, may indicate congestive heart failure.
- You are conducting a workshop on the measurement of jugular venous pulsation. As part of your instruction, you tell the students to make sure that they can distinguish between the jugular venous pulsation and the carotid pulse. Which one of the following characteristics is typical of the carotid pulse?
A) Palpable
B) Soft, rapid, undulating quality
C) Pulsation eliminated by light pressure on the vessel
D) Level of pulsation changes with changes in position
Ans: A
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Page and Header: 348, Techniques of Examination
Feedback: The carotid pulse is palpable; the jugular venous pulsation is rarely palpable. The carotid upstroke is normally brisk, but it may be delayed and decreased as in aortic stenosis or bounding as in aortic insufficiency.
- A 68-year-old mechanic presents to the emergency room for shortness of breath. You are concerned about a cardiac cause and measure his jugular venous pressure (JVP). It is elevated. Which one of the following conditions is a potential cause of elevated JVP?
A) Left-sided heart failure
B) Mitral stenosis
C) Constrictive pericarditis
D) Aortic aneurysm
Ans: C
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Page and Header: 348, Techniques of Examination
Feedback: One cause of increased jugular venous pressure is constrictive pericarditis. Others include right-sided heart failure, tricuspid stenosis, and superior vena cava syndrome. You may wish to read about these conditions.
- You are palpating the apical impulse in a patient with heart disease and find that the amplitude is diffuse and increased. Which of the following conditions could be a potential cause of an increase in the amplitude of the impulse?
A) Hypothyroidism
B) Aortic stenosis, with pressure overload of the left ventricle
C) Mitral stenosis, with volume overload of the left atrium
D) Cardiomyopathy
Ans: B
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Page and Header: 348, Techniques of Examination
Feedback: Pressure overload of the left ventricle, such as occurs in aortic stenosis, may result in an increase in amplitude of the apical impulse. The other conditions should decrease amplitude of the apical impulse or not be palpable at all.
- You are performing a cardiac examination on a patient with shortness of breath and palpitations. You listen to the heart with the patient sitting upright, then have him change to a supine position, and finally have him turn onto his left side in the left lateral decubitus position. Which of the following valvular defects is best heard in this position?
A) Aortic
B) Pulmonic
C) Mitral
D) Tricuspid
Ans: C
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Page and Header: 348, Techniques of Examination
Feedback: The left lateral decubitus position brings the left ventricle closer to the chest wall, allowing mitral valve murmurs to be better heard. If you do not listen to the heart in this position with both the diaphragm and bell in a quiet room, it is possible to miss significant murmurs such as mitral stenosis.
- You are concerned that a patient has an aortic regurgitation murmur. Which is the best position to accentuate the murmur?
A) Upright
B) Upright, but leaning forward
C) Supine
D) Left lateral decubitus
Ans: B
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Page and Header: 348, Techniques of Examination
Feedback: Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). You can further your ability to hear this soft murmur by having the patient hold his breath in exhalation.
- Where is the point of maximal impulse (PMI) normally located?
A) In the left 5th intercostal space, 7 to 9 cm lateral to the sternum
B) In the left 5th intercostal space, 10 to 12 cm lateral to the sternum
C) In the left 5th intercostal space, in the anterior axillary line
D) In the left 5th intercostal space, in the midaxillary line
Ans: A
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Feedback: The PMI is usually located in the left 5th intercostal space, 7 to 9 centimeters lateral to the sternal border. If it is located more laterally, it usually represents cardiac enlargement. Its size should not be greater than the size of a US quarter, or about an inch. Left ventricular enlargement should be suspected if it is larger. The PMI is often the best place to listen for mitral valve murmurs as well as S3 and S4. The PMI is often difficult to feel in normal patients.
- Which of the following events occurs at the start of diastole?
A) Closure of the tricuspid valve
B) Opening of the pulmonic valve
C) Closure of the aortic valve
D) Production of the first heart sound (S1)
Ans: C
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Page and Header: 323, Anatomy and Physiology
Feedback: At the beginning of diastole, the valves which allow blood to exit the heart close. It is thought that the closure of the aortic valve produces the second heart sound (S2). Closure of the mitral valve is thought to produce the first heart sound (S1).
- Which is true of a third heart sound (S3)?
A) It marks atrial contraction.
B) It reflects normal compliance of the left ventricle.
C) It is caused by rapid deceleration of blood against the ventricular wall.
D) It is not heard in atrial fibrillation.
Ans: C
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Page and Header: 323, Anatomy and Physiology
Feedback: The S3 gallop is caused by rapid deceleration of blood against the ventricular wall. S4 is heard with atrial contraction and is absent in atrial fibrillation for this reason. It usually indicates a stiff or thickened left ventricle as in hypertension or left ventricular hypertrophy.
- Which is true of splitting of the second heart sound?
A) It is best heard over the pulmonic area with the bell of the stethoscope.
B) It normally increases with exhalation.
C) It is best heard over the apex.
D) It does not vary with respiration.
Ans: A
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Feedback: S2 splitting is best heard over the pulmonic area because this is the only place where both of its components can be heard well. The closure of the pulmonic valve is normally not loud because the right heart is a low-pressure system. The bell is best used because it is a low-pitched sound. S2 splitting normally increases with inhalation.
- Which of the following is true of jugular venous pressure (JVP) measurement?
A) It is measured with the patient at a 45-degree angle.
B) The vertical height of the blood column in centimeters, plus 5 cm, is the JVP.
C) A JVP below 9 cm is abnormal.
D) It is measured above the sternal notch.
Ans: B
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Page and Header: 323, Anatomy and Physiology
Feedback: Measurement of the JVP is important to assess a patient’s fluid status. Although it may be measured at 45°, it is important to adjust the level of the patient’s torso so that the blood column is visible. This may be with the patient completely supine or sitting completely upright, depending on the patient. Any measurement greater than 4 cm above the sternal angle is abnormal. This would correspond to a JVP of 9 cm because we add a constant of 5 cm, which is an estimate of the height of the sternal notch above the right atrium.
- In measuring the jugular venous pressure (JVP), which of the following is important?
A) Keep the patient’s torso at a 45-degree angle.
B) Measure the highest visible pressure, usually at end expiration.
C) Add the vertical height over the sternal notch to a 5-cm constant.
D) Realize that a total value of over 12 cm is abnormal.
Ans: B
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: In measuring JVP, the angle of the patient’s torso must be varied until the highest oscillation point, or meniscus is visible. This varies. The landmark used is actually the sternal angle, not the sternal notch. We assign a constant height of 5 cm above the right atrium to this landmark. A value of over 8 cm total (more than 3 cm vertical distance above the sternal angle, plus the 5 cm constant) is considered abnormal.
- You find a bounding carotid pulse on a 62-year-old patient. Which murmur should you search out?
A) Mitral valve prolapse
B) Pulmonic stenosis
C) Tricuspid insufficiency
D) Aortic insufficiency
Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: Bounding carotid pulses would be found in aortic insufficiency. This should be sought by listening over the third left intercostal space, with the patient leaning forward in held exhalation. This is a very soft diastolic murmur usually. A bounding pulse may also be seen in any condition which increases cardiac output, including stimulant use, anxiety, hyperthyroidism, fever, etc.
- To hear a soft murmur or bruit, which of the following may be necessary?
A) Asking the patient to hold her breath
B) Asking the patient in the next bed to turn down the TV
C) Checking your stethoscope for air leaks
D) All of the above
Ans: D
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Page and Header: 348, Techniques of Examination
Feedback: All examiners should carefully search for soft murmurs and bruits. These can have great clinical significance. A quiet patient and room, as well as an intact stethoscope, will greatly increase your ability to hear soft sounds.
- Which of the following may be missed unless the patient is placed in the left lateral decubitus position and auscultated with the bell?
A) Mitral stenosis murmur
B) Opening snap of the mitral valve
C) S3 and S4 gallops
D) All of the above
Ans: D
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Page and Header: 348, Techniques of Examination
Feedback: Placing the patient in the left lateral decubitus position and auscultating with the bell will enable you to hear these sounds, which would otherwise be missed.
- How should you determine whether a murmur is systolic or diastolic?
A) Palpate the carotid pulse.
B) Palpate the radial pulse.
C) Judge the relative length of systole and diastole by auscultation.
D) Correlate the murmur with a bedside heart monitor.
Ans: A
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Page and Header: 348, Techniques of Examination
Feedback: Timing of a murmur is crucial for identification. The carotid pulse should be used because there is a delay in the radial pulse relative to cardiac events, which can lead to error. Some clinicians can estimate timing by the relative length of systole and diastole, but this method is not reliable at faster heart rates. A bedside monitor is not always available, nor are all designed to correlate in time with the actual pulse.
- Which of the following correlates with a sustained, high-amplitude PMI?
A) Hyperthyroidism
B) Anemia
C) Fever
D) Hypertension
Ans: D
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Page and Header: 348, Techniques of Examination
Feedback: While hyperthyroidism, anemia, and fever can cause a high-amplitude PMI, pressure work by the heart, as seen in hypertension, causes the PMI to be sustained.
- You are examining a patient with emphysema in exacerbation and are having difficulty hearing his heart sounds. What should you do to obtain a good examination?
A) Listen in the epigastrium.
B) Listen to the patient in the left lateral decubitus position.
C) Ask the patient to hold his breath for 30 seconds.
D) Listen posteriorly.
Ans: A
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Page and Header: 348, Techniques of Examination
Feedback: It is often difficult to hear the heart well in a patient with emphysema. The shape of the chest as well as the interfering lung noise make examination challenging. By listening in the epigastrium, these barriers can be overcome. It is impractical to ask a patient who is short of breath to hold his breath for a prolonged period. Listening posteriorly would make the heart sounds even softer. It is always a good idea to listen to a patient in the left lateral decubitus position, but in this case it would not make auscultation easier.
- You are listening carefully for S2 splitting. Which of the following will help?
A) Using the diaphragm with light pressure over the 2nd right intercostal space
B) Using the bell with light pressure over the 2nd left intercostal space
C) Using the diaphragm with firm pressure over the apex
D) Using the bell with firm pressure over the lower left sternal border
Ans: B
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Page and Header: 348, Techniques of Examination
Feedback: S2 splitting is composed of an aortic and pulmonic component. Because the pulmonic component is softer, it can usually be heard only over the 2nd left intercostal space. It is a low-pitched sound and thus should be sought using the bell with light pressure. Conversely, the diaphragm is best used with firm pressure.
- Which of the following is true of a grade 4-intensity murmur?
A) It is moderately loud.
B) It can be heard with the stethoscope off the chest.
C) It can be heard with the stethoscope partially off the chest.
D) It is associated with a “thrill.”
Ans: D
Chapter: 09
Page and Header: 348, Techniques of Examination
Feedback: The grade 4 murmur is differentiated from those below it by the presence of a palpable thrill. A murmur cannot be graded as a 4 unless this is present. The thrill is a “buzzing” feeling over the area where the murmur is loudest. For practice, you may often feel a thrill over a dialysis fistula.
- Which valve lesion typically produces a murmur of equal intensity throughout systole?
A) Aortic stenosis
B) Mitral insufficiency
C) Pulmonic stenosis
D) Aortic insufficiency
Ans: B
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Page and Header: 348, Techniques of Examination
Feedback: This description fits a holosystolic murmur. Because aortic and pulmonic stenosis murmurs vary with the flow of blood during systole, they typically produce a crescendo–decrescendo murmur. The murmur of aortic insufficiency represents backleak across the valve in diastole. It is a decrescendo pattern murmur, which gets softer as the pressure gradient decreases.
