Chapter 9, Module 5; PTQ Flashcards
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
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
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
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
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 screening people at the mall as part of a health fair. The first person who comes for screening has a blood pressure of 132/85. How would you categorize this?
A) Normal
B) Prehypertension
C) Stage 1 hypertension
D) Stage 2 hypertension
Ans: B
Feedback: Prehypertension is considered to be a systolic blood pressure from 120 to 139 and a diastolic BP from 80 to 89. Previously, this was considered normal. JNC 7 recommends taking action at this point to prevent worsening hypertension. Research shows that this population is likely to progress to more serious stages of hypertension.
You are participating in a health fair and performing cholesterol screens. One person has a cholesterol of 225. She is concerned about her risk for developing heart disease. Which of the following factors is used to estimate the 10-year risk of developing coronary heart disease?
A) Ethnicity
B) Alcohol intake
C) Gender
D) Asthma
Ans: C
Feedback: Gender is used in the calculation of the 10-year risk for developing coronary heart disease, because men have a higher risk than women.
You are evaluating a 40-year-old banker for coronary heart disease risk factors. He has a history of hypertension, which is well-controlled on his current medications. He does not smoke; he does 45 minutes of aerobic exercise five times weekly. You are calculating his 10-year coronary heart disease risk. Which of the following conditions is considered to be a coronary heart disease risk equivalent?
A) Hypertension
B) Peripheral arterial disease
C) Systemic lupus erythematosus
D) Chronic obstructive pulmonary disease (COPD)
Ans: B
Feedback: Peripheral arterial disease is considered to be a coronary heart disease risk equivalent, as are abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus.
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
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
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
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
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
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.
A 68-year-old retired waiter comes to your clinic for evaluation of fatigue. You perform a cardiac examination and find that his pulse rate is less than 60. Which of the following conditions could be responsible for this heart rate?
A) Second-degree A-V block
B) Atrial flutter
C) Sinus arrhythmia
D) Atrial fibrillation
Ans: A
Feedback: A second-degree A-V block can result in a pulse rate less than 60. Atrial flutter and atrial fibrillation do not cause bradycardia unless there is a significant accompanying block. Sinus arrhythmia does not cause bradycardia and represents respiratory variation of the heart rate.
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
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
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
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
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
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.
Which of the following regarding jugular venous pulsations is a systolic phenomenon?
A) The “y” descent
B) The “x” descent
C) The upstroke of the “a” wave
D) The downstroke of the “v” wave
Ans: B
Feedback: The most prominent upstrokes of jugular venous pulsations are diastolic phenomena. These can be timed using the carotid pulse. The only event listed above which is a systolic phenomenon is the “x” descent.
How much does cardiovascular risk increase for each increment of 20 mm Hg systolic and 10 mm Hg diastolic in blood pressure?
A) 25%
B) 50%
C) 75%
D) 100%
Ans: D
Feedback: Each increase of BP by 20 systolic and 10 diastolic doubles the risk of cardiovascular disease. Being “low risk” by JNC 7 criteria confers a 72%–85% reduction in CVD mortality and 40%–58% reduction in overall mortality.
In healthy adults over 20, how often should blood pressure, body mass index, waist circumference, and pulse be assessed, according to American Heart Association guidelines?
A) Every 6 months
B) Every year
C) Every 2 years
D) Every 5 years
Ans: C
Feedback: AHA guidelines recommend screening every 2 years in patients over 20 for blood pressure, body mass index, waist circumference, and pulse.
Which of the following is a clinical identifier of metabolic syndrome?
A) Waist circumference of 38 inches for a male
B) Waist circumference of 34 inches for a female
C) BP of 134/88 for a male
D) BP of 128/84 for a female
Ans: C
Feedback: The physical examination criteria for identifying metabolic syndrome include a waist of 40 inches or greater for a male, a waist of 35 inches or greater for a female, and a blood pressure of 130/85 or greater. Other criteria include triglycerides greater than or equal to 150 mg/dL, fasting glucose greater than or equal to 110 mg/dL, and HDL less than 40 for men or less than 50 for women.
Mrs. Adams would like to begin an exercise program and was told to exercise as intensely as necessary to obtain a heart rate 60% or greater of her maximum heart rate. She is 52. What heart rate should she achieve?
A) 80
B) 100
C) 120
D) 140
Ans: B
Feedback: Maximum heart rate is calculated by subtracting the patient’s age from 220. For Mrs. Adams, 60% of this number is about 100. She must also be instructed in how to measure her own pulse or have a device to do so. Most people are able to carry on a conversation at this level of exertion.
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
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.
