Module 8/9 - Heart Sounds and Murmurs

Question 1

auscultating sounds

Answer 1

APTM

Question 2

systole

Answer 2

ejecting blood out
SAPO

systolic aortic pulmonic open
systolic mitral tricuspid shut

Question 3

diastole

Answer 3

DAPS

diastole aortic pulmonic shut
diastole aortic pulmonic open

Question 4

S3 *

Answer 4

usually means that ventricular compliance is subnormal

STRONG INDICATOR OF EARLY HEART FAILURE

• more likely heard with inspiration after exercise, tachy, elevation of legs
• S3 in child/young adult pathophysiologic and disappears when standing
• best heard with bell at apex in LLD position

Question 5

S4 *

Answer 5

• called an atrial gallop (heard last third of diastole, just prior to S1)
• almost always abnormal
• due to blood rushing into ventricle with decreased compliance
  -Conditions: LVH (HTN, AS), CHD (ischemia or infarction)
• best heard with bell at apex in LLD position

Question 6

Blowing Quality*

Answer 6

MR, TR, AI, VSD

diaphragm
high pitch

Question 7

Harsh/Rough Quality *

Answer 7

AS, PR, ASD

diaphragm or bell
medium pitch

Question 8

Rumble Quality *

Answer 8

MS

bell
low pitch

Question 9

MR physical exam *

Answer 9

HOLOSYSTOLIC MURMUR THAT RADIATES FROM APEX TO AXILLA

• apex laterally displaced
• S2 may be split
• louder with LLD or hand grip

EKG changes:
- AFib

CXR changes:
- LA enlargement
- LVH
- CHF

Question 10

AS physical exam *

Answer 10

• intensity does not predict severity
• thrill does not predict severity
• crescendo pattern
• RADIATES TO CAROTIDS OR TOWARDS THE NECK
• displaced PMI with heave
• S3 with LV failure

Question 11

MS physical exam *

Answer 11

• small volume pulse

Ausculatate: LLD
- S1 is accentuated + snapping
- opening snap after AV closure
- low pitch diastolic RUMBLE at apex

Question 12

Drugs in the class of HMG-CoA reductase inhibitors can cause which of the following complications (particularly if combined with fibric acid derivatives)?

Answer 12

Myositis and rhabdo are toxic affects of HMG-CoA inhibitors (statin)

note: one does not generally combine statins with fibrates because of the side effects get worse when they are combined

Question 13

63yo female with history of DM presents for BP follow up. Her last two visits her BP was 150/92 and 152/96. Today her BP is 156/92. Recent blood work shows Na of 140, K 4.2, BUN 23, Cr 1.1

which of the following is the most appropriate initial medication choice

Answer 13

lisinopril

ACE should be a part of the initial treatment of HTN in DM bc of beneficial side effects in DM neuropathy. Diuretic should be added if ineffective

Question 14

74yo diagnosed with PNA. PA should ensure the patient is not on which of the following before starting therapy with clarithromycin

Answer 14

simvastatin

statins interact with macrolides and may cause QT prolongation, myopathy and rhabdo

Question 15

Which of the following antihypertensive agents is MOST apt to increase plasma LDL with long term use

Answer 15

THIAZIDE DIURETICS
elevated LDL/HDL

BB (except labetalol, pindolol)

Question 16

Which of the following population groups represent the greatest risk for developing primary HTN

Answer 16

black non hispanic

Question 17

68yo female in for annual visit. PMHx significant for 40pack year cig smoking. Takes no medication and no hosp/surg. Fam Hx reveals mother is living age 87 in good health, father died 45yo MVA. Two siblings alive and well.

How many identifiable risk factors for cardiovascular heart disease exist?

Answer 17

2

age and cig smoking

Question 18

Eliciting a history from a patient presenting with dyspnea due to early heart failure the severity of dyspnea should be quantified by

Answer 18

amount of activity that precipitates it

Question 19

non HDL level

Answer 19

TC - HDL

Question 20

46yo female being evaluated for a new onset HTN that was discovered on a screening. no meds, PE unremarkable. Labs show hypokalemia.

Most likely diagnosis of patient

Answer 20

primary aldosteronism

primary aldosteronism has an increased aldosterone secretion, which causes the retention of sodium and the loss of potassium.

Question 21

Pt receiving simvastatin 80mg/day for past 6mo. 2 weeks ago he was diagnosed with HTN and was started on verapamil 240mg/day. Patient in clinic today with complaints of aches in arms and legs. What lab should be tested

Answer 21

CK