Pericardial disease Flashcards
Pericardial Disease / Will Kill)
A patient complaining of chest pain improved by leaning forward has a friction rub on auscultation. Which acute complication can lead to death if missed?
A. Referred shoulder pain
B. Cardiac tamponade
C. Benign effusion
D. Pericardial calcification
Correct Answer: B. Cardiac tamponade
Rationale:
In pericardial disease, particularly pericarditis, an acute complication that can be life-threatening if missed is cardiac tamponade. This occurs when fluid rapidly accumulates in the pericardial space, compressing the heart and impairing its ability to fill and pump effectively. The other options, such as referred shoulder pain, benign effusion, or pericardial calcification, are not immediate threats to life in the acute setting.
In acute pericarditis, which EKG finding is typically seen across multiple leads?
A. ST depression only
B. Diffuse ST elevation with PR depression
C. Delta waves
D. Peaked T waves
Correct Answer: B. Diffuse ST elevation with PR depression
Rationale:
In acute pericarditis, the classic EKG pattern includes diffuse ST segment elevation across multiple leads along with PR segment depression. This pattern reflects the widespread inflammation of the pericardium. The other options—ST depression only, delta waves, or peaked T waves—are not characteristic of acute pericarditis.
- In acute pericarditis, what is “really common” on physical exam?
A. Pericardial friction rub
B. Loud S1 without murmur
C. Ventricular gallop
D. Fixed split S2
o Answer: A
o Rationale: A pericardial friction rub is a hallmark finding in pericarditis.
- Which complication “will kill your patient” in the context of pericardial disease?
A. Pericardial friction rub
B. Cardiac tamponade
C. Mild chest discomfort
D. Transient arrhythmia
o Answer: B
o Rationale: Cardiac tamponade is a life-threatening complication that leads to reduced cardiac output and shock.
- A patient with acute pericarditis suddenly becomes hypotensive and tachycardic. Which complication should you suspect immediately?
A. Constrictive pericarditis
B. Cardiac tamponade
C. Pericardial friction rub
D. Chronic pericarditis
o Answer: B
o Rationale: Cardiac tamponade causes reduced cardiac output due to pressure on the heart, leading to hypotension and tachycardia, representing an immediate life-threatening complication.
- In the early (stage I) phase of acute pericarditis, what EKG finding is most characteristic?
A. Diffuse T-wave inversions
B. Localized ST depression
C. Widespread ST elevation with upward concavity
D. Prolonged QT interval
o Answer: C
o Rationale: Stage I of pericarditis typically shows diffuse ST elevation with an upward concavity in multiple leads, distinguishing it from localized changes seen in myocardial infarction.
- Which complication is most directly associated with the use of NSAIDs in pericarditis management?
A. Renal failure
B. Gastric ulceration
C. Hepatotoxicity
D. Arrhythmias
o Answer: B
o Rationale: NSAIDs can cause gastric mucosal damage, increasing the risk of peptic ulcers, which is why gastroprotective agents are often co-administered.
- On physical exam, what is the most common auscultatory finding in a patient with acute pericarditis?
A. S3 gallop
B. Pericardial friction rub
C. Systolic murmur
D. Crackles at lung bases
o
Answer: B
o Rationale: A pericardial friction rub is a hallmark of pericarditis, heard in approximately 85% of cases, due to the inflamed pericardial surfaces rubbing together.
- Which chest X-ray appearance is classically associated with a significant pericardial effusion?
A. “Snowman sign”
B. “Water bottle” heart silhouette
C. “Egg on a string” appearance
D. “Boot-shaped” heart
o Answer: B
o Rationale: The “water bottle” silhouette is typical for a large pericardial effusion as the heart appears enlarged and globular.
- To assess for a pericardial effusion and possible tamponade, which imaging modality is most useful?
A. Abdominal ultrasound
B. Echocardiogram
C. Plain chest X-ray
D. Coronary angiography
o Answer: B
o Rationale: Echocardiography is the gold standard for evaluating pericardial effusions and determining their hemodynamic significance, including signs of tamponade.
- A patient with suspected pericarditis finds that his pain improves when he sits up and leans forward. What does this most likely indicate?
A. Myocardial infarction
B. Aortic dissection
C. Pericarditis
D. Pulmonary embolism
o Answer: C
o Rationale: Relief of chest pain on leaning forward is a classic finding in pericarditis because this position reduces the pressure between the inflamed pericardial layers.
- Which laboratory markers are typically elevated in an inflammatory pericarditis? (Select all that apply)
A. Erythrocyte sedimentation rate (ESR)
B. C-reactive protein (CRP)
C. Lactate dehydrogenase (LDH)
D. Brain natriuretic peptide (BNP)
Answer: A, B, C
o Rationale: ESR, CRP, and LDH are markers of inflammation and are often elevated in pericarditis. BNP is more associated with heart failure.
- The pathophysiology of acute pericarditis involves an inflammatory process. Which cells predominantly infiltrate the pericardium in the early phase?
A. Lymphocytes
B. Neutrophils
C. Eosinophils
D. Basophils
o.
Answer: B
o Rationale: In the early stages, neutrophils are the primary inflammatory cells involved in acute pericarditis
- What is the initial pharmacologic management for a patient with idiopathic acute pericarditis?
A. Beta-blockers
B. NSAIDs (e.g., ibuprofen) with or without aspirin
C. Calcium channel blockers
D. ACE inhibitors
o Answer: B
o Rationale: NSAIDs are the first-line treatment to reduce inflammation and alleviate pain in idiopathic acute pericarditis.
- In a patient who does not respond to NSAIDs and colchicine, what is the next step in pharmacologic therapy for pericarditis?
A. Increase NSAID dose
B. Start glucocorticoids (e.g., prednisone)
C. Add a beta-blocker
D. Initiate antibiotic therapy
o Answer: B
o Rationale: Glucocorticoids are reserved for cases that are refractory to NSAIDs and colchicine or in patients who cannot tolerate these medications
- What EKG finding suggests a very large pericardial effusion?
A. Electrical alternans
B. Delta waves
C. Peaked T waves
D. Prolonged PR interval
o Answer: A
o Rationale: Electrical alternans, a beat-to-beat variation in the amplitude of the QRS complexes, is classically associated with large pericardial effusions
- Which organism is most commonly implicated in the bacterial (pyogenic) form of infectious pericarditis?
A. Streptococcus pneumoniae
B. Mycobacterium tuberculosis
C. Staphylococcus aureus
D. Escherichia coli
o Answer: C
o Rationale: Staphylococcus aureus is a common pathogen in acute bacterial (pyogenic) pericarditis, often following bacteremia or pneumonia
- For pericarditis to be considered “acute,” symptoms should have been present for less than:
A. 2 weeks
B. 6 weeks
C. 3 months
D. 6 months
o Answer: B
o Rationale: Acute pericarditis is defined as having a duration of symptoms for less than six weeks.
- Which clinical feature helps differentiate pericarditis chest pain from that of a myocardial infarction?
A. Radiation to the left arm
B. Pain relief by sitting forward
C. Severe crushing quality
D. Associated diaphoresis
o Answer: B
o Rationale: Pericarditis pain characteristically improves when the patient sits up and leans forward, unlike the pain of myocardial infarction.
- What is the primary reason that pericarditis pain is relieved by leaning forward?
A. It decreases the heart rate
B. It reduces compression of the coronary arteries
C. It alters the position of the heart to lessen pericardial stretch
D. It improves lung ventilation
Answer: C
o Rationale: Leaning forward minimizes the stretch on the inflamed pericardium by changing the position of the heart, thereby reducing pain.
- Which finding on chest imaging might be seen in both pericardial effusion and other mediastinal pathologies?
A. A “water bottle” configuration
B. Enlarged cardiac silhouette
C. Pneumomediastinum
D. Hyperlucent lung fields
o Answer: B
o Rationale: An enlarged cardiac silhouette on chest X-ray can be seen with pericardial effusion as well as other mediastinal abnormalities, although the “water bottle” sign is more specific.
- Which of the following complications is most concerning in a patient with a pericardial effusion?
A. Development of atrial fibrillation
B. Progression to cardiac tamponade
C. Onset of congestive heart failure
D. Evolution into restrictive cardiomyopathy
o Answer: B
o Rationale: Cardiac tamponade is an acute, life-threatening complication of a pericardial effusion that demands immediate intervention.
- A patient with pericarditis has a history of peptic ulcer disease. Which treatment consideration is most important?
A. Avoidance of beta-blockers
B. Co-administration of proton pump inhibitors with NSAIDs
C. Use of high-dose aspirin only
D. Early initiation of glucocorticoids
o Answer: B
o Rationale: Given the risk of gastrointestinal bleeding with NSAIDs, patients with peptic ulcer disease should receive acid suppression therapy.
- Pericarditis can be associated with autoimmune conditions. Which of the following diseases is most commonly linked with pericarditis?
A. Systemic lupus erythematosus (SLE)
B. Diabetes mellitus
C. Osteoarthritis
D. Hyperthyroidism
o Answer: A
o Rationale: SLE is a well-known autoimmune condition that frequently involves the pericardium, causing pericarditis.
- How can renal failure contribute to pericarditis?
A. By increasing blood viscosity
B. Through uremic toxin accumulation leading to inflammation
C. By causing hypertension
D. Via direct viral infection
Answer: B
o Rationale: Uremic pericarditis occurs when accumulated toxins in renal failure trigger an inflammatory response in the pericardium.
- Why is it important to taper anti-inflammatory medications in pericarditis management once symptoms improve?
A. To prevent rebound pericarditis
B. To avoid withdrawal headaches
C. Because the patient develops tolerance
D. To minimize the risk of arrhythmias
Answer: A
o Rationale: Tapering helps avoid a rebound inflammatory reaction that could precipitate recurrence of pericarditis symptoms.
- Which physical exam finding is present in approximately 85% of patients with pericarditis?
A. Pericardial friction rub
B. Jugular venous distension
C. Murmur of mitral regurgitation
D. Pulmonary rales
o Answer: A
o Rationale: The pericardial friction rub is a common and nearly pathognomonic physical exam finding in pericarditis.
- How do the EKG changes in pericarditis differ from those seen in myocardial infarction?
A. Pericarditis shows ST depression in V1-V3
B. Pericarditis produces diffuse ST elevation across multiple leads
C. MI produces diffuse T-wave inversion
D. MI shows PR segment elevation
o
Answer: B
o Rationale: Diffuse ST elevation without a localized coronary distribution is typical for pericarditis, whereas MI shows changes confined to specific regions.
- A patient with a history of recurrent acute pericarditis develops signs of heart failure. What chronic complication should be considered?
A. Restrictive cardiomyopathy
B. Constrictive pericarditis
C. Dilated cardiomyopathy
D. Aortic regurgitation
o Answer: B
o Rationale: Recurrent inflammation can lead to scarring and thickening of the pericardium, eventually causing constrictive pericarditis which mimics heart failure.
- Which imaging modality is best for evaluating the size of a pericardial effusion?
A. Echocardiogram
B. Chest CT scan
C. Cardiac catheterization
D. MRI
o Answer: A
o Rationale: An echocardiogram provides real-time visualization of the effusion and its effect on cardiac function.
- What is the recommended daily dose of aspirin in the management of acute pericarditis?
A. 81 mg once daily
B. 2 to 4 grams per day
C. 500 mg twice daily
D. 1 gram every 6 hours
o
Answer: B
o Rationale: High-dose aspirin (2–4 g/day) is used for its anti-inflammatory effects in treating acute pericarditis.
- Colchicine is used in the treatment of acute pericarditis primarily to:
A. Lower blood pressure
B. Enhance the response to NSAIDs and reduce recurrence
C. Increase heart rate
D. Act as a diuretic
o Answer: B
o Rationale: Colchicine reduces the risk of recurrence and works synergistically with NSAIDs to manage inflammation.
- Which of the following is a direct consequence of the inflammatory process in pericarditis?
A. Coronary artery spasm
B. Exudate formation and potential adhesion of pericardial layers
C. Ventricular hypertrophy
D. Mitral valve prolapse
o
Answer: B
o Rationale: Inflammation leads to exudate formation, and over time fibrin deposits can cause adhesions between the pericardial layers.
- Pericarditis lasting more than six months is classified as which of the following?
A. Acute pericarditis
B. Subacute pericarditis
C. Chronic pericarditis
D. Recurrent pericarditis
o.
Answer: C
o Rationale: Duration longer than six months meets the definition of chronic pericarditis
- Which complication represents the most immediate threat to a patient’s airway, breathing, or circulation in pericardial disease?
A. Pericardial friction rub
B. Cardiac tamponade
C. Constrictive pericarditis
D. Pericardial thickening
o
Answer: B
o Rationale: Cardiac tamponade can quickly lead to hemodynamic collapse, posing an immediate risk to ABCs (Airway, Breathing, Circulation).
- Which lab test is most useful in demonstrating the inflammatory nature of pericarditis?
A. Troponin
B. Erythrocyte sedimentation rate (ESR)
C. D-dimer
D. Serum potassium
o
Answer: B
o Rationale: An elevated ESR is a sensitive marker of systemic inflammation and supports the diagnosis of pericarditis.
- Which of the following drugs is known to potentially cause drug-induced pericarditis?
A. Acetaminophen
B. Procainamide
C. Metformin
D. Lisinopril
o Answer: B
o Rationale: Procainamide has been associated with drug-induced pericarditis due to an autoimmune reaction.
- A widened mediastinum on chest X-ray in a patient with pericardial disease might raise concern for which additional pathology?
A. Aortic dissection
B. Pulmonary edema
C. Pneumonia
D. Rib fracture
o Answer: A
o Rationale: A widened mediastinum is concerning for aortic dissection, which can coexist with or mimic pericardial pathology.
- The pericardium serves an important function by preventing sudden dilation of the cardiac chambers. This is primarily achieved by:
A. The fibrous pericardium’s restraining force
B. The rapid absorption of pericardial fluid
C. Myocardial contractility
D. Coronary blood flow regulation
o.
Answer: A
o Rationale: The fibrous pericardium provides a restraining effect on the heart, preventing excessive dilation during abrupt changes in volume
- Which change in a patient’s posture is most typically seen as a response to pericardial pain?
A. Leaning backward
B. Slouching
C. Sitting forward with a tripod position
D. Lying flat
o Answer: C
o Rationale: Patients with pericarditis often adopt a sitting-forward (tripod) position to reduce the stretch on the pericardium and ease the pain.
- PR segment depression on the EKG of a patient with pericarditis is most indicative of:
A. Atrial injury
B. Ventricular ischemia
C. Conduction delay
D. Bundle branch block
o Answer: A
o Rationale: PR segment depression is a sign of atrial involvement, reflecting inflammation of the atrial myocardium adjacent to the pericardium.
- Idiopathic pericarditis is most often:
A. Caused by a known bacterial infection
B. A diagnosis made after excluding other causes
C. Always associated with autoimmune disease
D. Due to trauma
o Answer: B
o Rationale: When no clear etiology is identified, pericarditis is classified as idiopathic, meaning it is diagnosed by excluding other causes.
- During the progression of pericarditis, the formation of fibrin deposits can lead to:
A. Rapid myocardial healing
B. Adhesion between pericardial layers
C. Coronary artery plaque formation
D. Valvular stenosis
o Answer: B
o Rationale: Fibrin deposits promote adhesions between the visceral and parietal pericardium, which may lead to chronic complications.
- Which viral agent is most frequently associated with viral pericarditis?
A. Influenza virus
B. Coxsackie virus
C. HIV
D. Epstein-Barr virus
o Answer: B
o Rationale: Coxsackie virus is the most common cause of viral pericarditis, particularly in otherwise healthy individuals.
- What is the primary role of echocardiography in managing pericardial disease?
A. To assess coronary artery blockages
B. To evaluate the size and hemodynamic effect of a pericardial effusion
C. To measure pulmonary pressures
D. To detect myocardial infarction
o Answer: B
o Rationale: Echocardiography is essential to quantify the effusion and assess for tamponade physiology, guiding treatment decisions.
- To prevent gastrointestinal complications in patients receiving NSAIDs for pericarditis, what should be added to the treatment plan?
A. Diuretics
B. Proton pump inhibitors or H2 receptor blockers
C. Calcium supplements
D. Beta-blockers
o Answer: B
o Rationale: Co-administration of acid-suppressive therapy helps protect the gastrointestinal mucosa against NSAID-induced ulceration.
- The term “electrical alternans” on an EKG is most concerning for which pericardial complication?
A. Mild pericarditis
B. Large pericardial effusion
C. Early myocardial infarction
D. Valvular heart disease
Answer: B
o Rationale: Electrical alternans, reflecting the swinging motion of the heart in a large effusion, is a worrisome sign for tamponade.
- Which physical exam finding might suggest a large pericardial effusion aside from a friction rub?
A. Loud S1 heart sound
B. Distant or muffled heart sounds
C. Harsh systolic murmur
D. Early diastolic murmur
o Answer: B
o Rationale: Muffled or distant heart sounds occur when a significant effusion dampens the transmission of sound from the heart.
- An elevated lactate dehydrogenase (LDH) in a patient with suspected pericarditis supports which of the following?
A. A non-inflammatory process
B. An inflammatory process
C. Primary myocardial infarction
D. A hemorrhagic pericardial effusion
o Answer: B
o Rationale: LDH is released during cellular injury and inflammation, supporting an inflammatory etiology in pericarditis.
- Glucocorticoids in pericarditis are typically reserved for which scenario?
A. First-line treatment in all cases
B. Patients who fail or cannot tolerate NSAIDs/colchicine
C. Mild viral pericarditis
D. When pericardial effusion is minimal.
o Answer: B
o Rationale: Glucocorticoids are used when first-line anti-inflammatory agents are ineffective or contraindicated, despite their potential for side effects
- CT and MRI in the evaluation of pericardial disease are best used to:
A. Measure ejection fraction
B. Assess pericardial thickness and inflammation
C. Replace the need for echocardiography
D. Evaluate coronary artery calcifications
o
Answer: B
o Rationale: CT and MRI provide detailed imaging of pericardial anatomy, helping to assess thickening, inflammation, and chronic changes.
- Which patient position is most likely to alleviate chest pain in acute pericarditis?
A. Supine
B. Prone
C. Upright and leaning forward
D. Trendelenburg
o Answer: C
o Rationale: Sitting upright and leaning forward relieves the strain on the pericardium, thereby alleviating chest pain.
- Aside from pharmacologic interventions, what nonpharmacologic measure is important in the management of pericarditis?
A. Aggressive physical therapy
B. Bed rest and oxygen support if needed
C. High-intensity exercise
D. Immediate surgical intervention
o Answer: B
o Rationale: Rest and supportive care, such as oxygen therapy, help decrease metabolic demand and support recovery in pericarditis.
- Among the complications associated with pericardial effusion, which one poses the most immediate risk to circulatory collapse?
A. Chronic pericarditis
B. Cardiac tamponade
C. Constrictive pericarditis
D. Recurrent pericarditis
o Answer: B
o Rationale: Cardiac tamponade is the acute complication that can lead to rapid hemodynamic deterioration and circulatory collapse if not promptly treated.
- During the evolution of EKG changes in pericarditis, what change is typically seen in Stage II?
A. Worsening ST elevation
B. Return of the ST segments to baseline
C. Prominent T-wave inversion
D. Development of Q waves
o Answer: B
o Rationale: In Stage II of pericarditis, the ST segments typically normalize after the initial diffuse ST elevation of Stage I, preceding the T-wave inversion seen in Stage III.
- Which adverse effect is most commonly associated with colchicine therapy in pericarditis?
A. Diarrhea
B. Neuropathy
C. Bone marrow suppression
D. Renal insufficiency
o Answer: A
o Rationale: Colchicine is well known for its gastrointestinal side effects, particularly diarrhea, which is the most common adverse effect encountered during therapy.
- Which feature of chest pain is most helpful in distinguishing pericarditis from other causes of pleuritic chest pain such as pulmonary embolism?
A. Sudden onset of pain
B. Pain that is positional and improves when leaning forward
C. Associated dyspnea
D. Radiation of pain to the arm
o Answer: B
o Rationale: Chest pain from pericarditis classically improves when the patient sits up and leans forward, a positional change that is not typical of pulmonary embolism.
- Pericarditis that develops 10–14 days after a myocardial infarction is best described as:
A. Early post-MI pericarditis
B. Dressler’s syndrome
C. Viral pericarditis
D. Uremic pericarditis
o Answer: B
o Rationale: Dressler’s syndrome is an immune-mediated pericarditis that typically occurs weeks after myocardial infarction, distinguishing it from the early post-MI pericarditis that may occur within the first few days.
- Which of the following features can help differentiate constrictive pericarditis from restrictive cardiomyopathy?
A. Presence of a pericardial knock
B. Preservation of tissue Doppler velocities on echocardiography
C. Kussmaul’s sign (increased jugular venous pressure on inspiration)
D. All of the above
o Answer: D
o Rationale: Constrictive pericarditis is characterized by a pericardial knock, preserved myocardial velocities (on tissue Doppler imaging), and often a positive Kussmaul’s sign. These features help distinguish it from restrictive cardiomyopathy.
- Which diagnostic test is particularly useful for evaluating suspected tuberculous pericarditis?
A. Pericardial fluid analysis for adenosine deaminase (ADA) levels
B. Transesophageal echocardiography (TEE)
C. Cardiac MRI
D. Coronary angiography
o
Answer: A
o Rationale: Elevated ADA levels in pericardial fluid are strongly suggestive of tuberculous pericarditis, making fluid analysis a valuable diagnostic tool in the appropriate clinical context.
- In radiation-induced pericarditis, what is the primary pathophysiologic mechanism?
A. Direct pericardial injury leading to inflammation and fibrosis
B. Secondary infectious inflammation
C. An autoimmune reaction
D. A metabolic derangement
o Answer: A
o Rationale: Radiation can directly injure the pericardial tissues, resulting in inflammation and subsequent fibrosis, which is the main mechanism behind radiation-induced pericarditis
- Which finding on pericardial fluid analysis would suggest an exudative process?
A. Low protein content
B. High lactate dehydrogenase (LDH) level
C. Low white blood cell count
D. Transudative profile
o Answer: B
o Rationale: An exudative pericardial effusion is characterized by a high LDH level (among other findings such as high protein), indicating inflammation and increased capillary permeability.
- When a patient presents with cardiac tamponade, what is the immediate management step?
A. Urgent pericardiocentesis
B. Initiation of beta-blocker therapy
C. Administration of intravenous fluids only
D. Scheduled elective pericardiectomy
o Answer: A
o Rationale: Cardiac tamponade is an emergency. The immediate life-saving intervention is pericardiocentesis to relieve the pressure on the heart.
- What is the primary therapeutic role of NSAIDs in the management of acute pericarditis?
A. Acting as a diuretic to reduce pericardial fluid
B. Lowering heart rate to reduce cardiac workload
C. Reducing inflammation and alleviating pain
D. Preventing arrhythmias
o Answer: C
o Rationale: NSAIDs are used in acute pericarditis primarily for their anti-inflammatory properties, which help reduce inflammation and relieve the associated pain.
o Chest Pain: Severe, retrosternal, and often pleuritic.
Acute pericarditis
Clinical Presentation:
Pain typically improves when the patient sits up and leans forward due to reduced pericardial stretch.
o Positional Relief:
A pericardial friction rub is common (present in about 85% of cases).
o Auscultatory Findings
Diffuse ST elevation with upward concavity and PR segment depression
EKG Changes Stage I
EKG Changes Stage II
Stage II: Normalization of ST segments
EKG Changes Stage III
Stage III: T-wave inversion.
large pericardial effusion.
Electrical alternans may indicate
Chest X-ray of acute pericarditis
Can reveal an enlarged, “water bottle” cardiac silhouette.
The gold standard for assessing effusion size and hemodynamic impact.
Echocardiogram:
Elevated ESR, CRP, and LDH support an inflammatory process.
Laboratory Markers
(e.g., high-dose aspirin or ibuprofen) to reduce inflammation and alleviate pain
First-Line Therapy: NSAIDs
Colchicine is used to enhance the response and reduce recurrence.
Adjunctive Therapy:
Glucocorticoids (e.g., prednisone) are reserved for patients who do not respond to NSAIDs and colchicine.
Refractory Cases
Bed rest and oxygen support as needed, while monitoring for complications.
Supportive Measures
A life-threatening condition causing hemodynamic instability; requires immediate intervention (e.g., pericardiocentesis).
Cardiac Tamponade
- a complication
NSAID-induced gastric ulceration mandates gastroprotective measures (e.g., proton pump inhibitors).
Gastrointestinal Side Effects
May develop from persistent inflammation and fibrosis.
Chronic Constrictive Pericarditis:
Consider both infectious (viral, bacterial, tuberculous) and noninfectious (idiopathic, autoimmune, post-radiation, uremic) etiologies.
Underlying Causes
What abnormal heart sound would you apprehend when auscultating a patient with acute pericarditis?
A. Holosystolic murmur
B. Friction rub
C. Split S3
D. S4
B. Friction rub
