Murmur practice questions

A patient presents with moderate mitral stenosis. Which of the following complications is associated with an increased risk of systemic embolization in this patient? A. atrial fibrillation B. pulmonary hypertension C. increased left atrial pressure D. left ventricular dilatation

(c) A. 50-80% of patients with mitral stenosis will develop paroxysmal or chronic atrial fibrillation; 20-30% of patients with atrial fibrillation will have systemic embolization.

Which of the following heart murmurs is most likely to radiate into the axilla? A. Mitral insufficiency B. Mitral stenosis C. Aortic insufficiency D. Aortic stenosis

(c) A. MR produces a holosystolic murmur best heard at the apex and radiating to the axilla and back

A patient presents with a holosystolic murmur. Which of the following diagnoses is consistent with this finding? A. Mitral insufficiency B. Mitral stenosis C. Aortic insufficiency D. Aortic stenosis

(c) A. Mitral insufficiency murmur produces a holosystolic murmur best heard at the apex and radiating to the axilla and back. (u) D. The murmur of AS is a harsh, systolic, crescendo-decrescendo murmur that is best heard over the right sternal border and often radiated to the neck. As the stenosis increases, the "peak" of the murmur occurs later in systole.

On cardiac auscultation, you hear a mid-diastolic low-pitched mitral murmur heard best at the cardiac apex. The presence of this sound is most characteristic of which valvular abnormality? A. Aortic regurgitation B. Mitral regurgitation C. Pulmonic stenosis D. Tricuspid stenosis

(c) A. The Austin Flint murmur is a mid or late diastolic low-pitched mitral murmur heard in advanced aortic regurgitation, owing to partial obstruction of mitral inflow produced by partial closure of the mitral valve by the regurgitant jet and the rapidly rising left ventricular diastolic pressure.

An elderly female presents for evaluation of exertional syncope, dyspnea, and angina. She admits that previous to these symptoms she had insidious progression of fatigue that caused her to curtail her activities. Which of the following is the most likely diagnosis? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral valve prolapse

(c) A. The major symptoms of aortic stenosis are exertional syncope, dyspnea, and angina. Symptoms do not become apparent for a number of years and usually are not present until the valve is narrowed to less than 0.5 cm to 2 cm of valve surface area.

An 18 year-old male high school basketball player comes to clinic for a routine physical exam. His height is 193 cm (76 in.); arm span is 201 cm (79 in.). He has long fingers and toes. Blood pressure is 146/62 mmHg and pulse is 64/min. Which of the following exam findings is most consistent with the diagnosis? A. Grade 2/6 high-frequency diastolic murmur at the third right intercostal space B. Grade 2/6 systolic ejection murmur at the second left intercostal space with a fixed widely split S2 C. Grade 2/6 continuous murmur heard best at the high left sternal border D. Grade 2/6 systolic murmur at the fourth left intercostal space that decreases with squatting

(c) A. This murmur is most consistent with aortic regurgitation which can be present in patients with Marfans syndrome and a dilated aortic root.

A 75 year-old female with a history of long-standing hypertension presents with shortness of breath. On examination you note a diastolic murmur at the left upper sternal border. Which of the following maneuvers would accentuate this murmur? A. Sitting up and leaning forward B. Lying on left side C. Performing Valsalva maneuver D. Standing upright

(c) A. This patient has history findings consistent with aortic insufficiency which is characterized by a diastolic murmur that is accentuated when the patient sits up and leans forward.

Which of the following is an absolute contraindication for the performance of exercise stress testing for patients who wish to start an exercise program? A. Second degree heart block type 1 B. Severe aortic stenosis C. Atrial fibrillation with controlled ventricular response D. Recent diagnosis of lung cancer

(c) B. Contraindications to stress testing include rest angina within the last 48 hours, unstable cardiac rhythm, hemodynamically unstable patient, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, and active infective endocarditis.

Which of the following would you expect on physical examination in a patient with mitral valve stenosis? A. Systolic blowing murmur B. Opening snap C. Mid-systolic click D. Paradoxically split S2

(c) B. Mitral stenosis is characterized by a mid-diastolic opening snap.

The most common arrhythmia encountered in patients with mitral stenosis is A. atrial flutter. B. atrial fibrillation. C. paroxysmal atrial tachycardia. D. atrio-ventricular dissociation.

(c) B. Mitral stenosis leads to enlargement of the left atrium, which is the major predisposing risk factor for the development of atrial fibrillation.

The highest pressure gradients between the left ventricle and the aorta occurs with which of the following valvular abnormalities? A. Aortic regurgitation B. Aortic stenosis C. Mitral stenosis D. Mitral regurgitation

(c) B. The aortic valve is a tricuspid valve that is positioned between the left ventricle and the aorta. The valve is open during systole and closed during diastole. In AS, the highest pressure gradient differences between the left ventricle and aorta will be seen. As AS progresses, the pressure in the left atrium will increase as the aortic stenosis worsens and blood is unable to leave the left ventricle. The pressure in the aorta will decrease secondary to the progressing outlet obstruction.

A patient's carotid pulse has a quick upstroke associated with wide pulse pressure. These findings are suggestive of A. mitral stenosis. B. pericardial tamponade. C. aortic regurgitation. D. congestive heart failure.

(c) C. Aortic regurgitation causes a bounding pulse and this is characteristic of conditions caused by increased stroke volume and decreased peripheral resistance.

A 13 year-old patient is hospitalized with a fever of 102.5 F and a rash. After 36 hours the rash has rapidly progressed to enlarging macules that appear ring orcrescent shaped with central clearing. He also complains of multiple arthralgias involving his ankles, knees, and now his elbows. The electrocardiogram shows evidence of a first degree AV block. Labs were significant for an elevated erythrocyte sedimentation rate and leukocytosis. Which of the following physical examination findings would be most likely in this patient? A. Cord-like palpable calf vein B. Diminished lower extremity pulses C. Mitral regurgitation murmur D. Oral cyanosis

(c) C. Jones criteria of rheumatic fever include 1 major (erythema marginatum) and 3 minor (fever, polyarthralgies, prolonged PR

A patient presents with a heart murmur that occurs when regurgitant blood in the left ventricle strikes the anterior leaflet of the mitral valve. Which of the following would best describe this murmur? A. High-pitched sound following S2 B. Low-pitched rumbling diastolic murmur C. Soft, low-pitched rumbling mid-diastolic murmur D. Holosystolic murmur

(c) C. The Austin Flint murmur is a soft, low-pitched, rumbling mid-diastolic bruit. It is produced by the displacement of the anterior leaflet of the mitral valve by the aortic regurgitation stream but does not appear to be associated with hemodynamically significant mitral obstruction.

Which of the following physical exam findings suggests worsening or severe aortic stenosis? A. An ejection click preceding the murmur B. A split S2 with respiration variation C. Grade 2/6 systolic murmur radiating to the carotids D. Palpable thrill over the right second intercostal space

(c) D. A palpable thrill or LV heave with associated murmur suggests severe AS

Which of the following is the most likely initial effect on the left ventricle from aortic stenosis? A. Dilation of the ventricle with diastolic dysfunction B. Wall stiffness due to ischemia from decreased coronary blood flow C. Paradoxical wall motion abnormalities due to increased preload D. Concentric hypertrophy with preserved function

(c) D. Hypertrophy would be the initial changes of the left ventricle as a response to the increased pressure.

Which of the following valvular heart abnormalities will most likely be seen on echocardiography as a complication of acute myocardial infarction? A. Aortic stenosis B. Aortic regurgitation C. Mitral stenosis D. Mitral regurgitation

(c) D. In patients with acute myocardial infarction, echocardiogram can show the severity of mitral regurgitation and the presence of ventricular septal defect if one is present. Acute inferior wall myocardial infarction is associated with acute mitral regurgitation due to necrosis of the posterior papillary muscle which is supplied by the right coronary artery.

Which of the following physical examination findings is consistent with chronic aortic regurgitation? A. Cannon wave visualized on examination of jugular venous pressure B. Decreased blood pressure in the lower extremity compared to upper C. Dependent edema D. Wide pulse pressure

(c) D. Major physical examination findings in chronic aortic regurgitation relate to the high stroke volume being ejected into the systemic vascular system with rapid runoff as the regurgitation takes place. This results in a wide pulse pressure.

A patient had an acute inferior, transmural myocardial infarction 4 days ago. A new murmur raises the suspicion of mitral regurgitation due to papillary muscle rupture. Which of the following murmur descriptions describes this condition? A. A grade III/VI diastolic murmur heard best at the apex without radiation. B. A grade IV/VI systolic ejection murmur heard best at the base with radiation to the left clavicle. C. A grade II/VI systolic murmur heard best at the apex preceded by a click and without radiation. D. A grade IV/VI systolic murmur heard best at the apex with radiation to the left axilla.

(c) D. This is a classic description of mitral regurgitation. The papillary muscle rupture is a complication of an acute inferior transmural myocardial infarction, and results in a failure of the mitral valve leaflets to close. The direction of regurgitant flow of blood is toward the left axilla.

A 56 year-old female four days post myocardial infarction presents with a new murmur. On examination the murmur is a grade 3/6 pansystolic murmur radiating to the axilla. She is dyspenic at rest and has rales throughout all her lung fields. Blood pressure is 108/68 mmHg, pulse 70 bpm. Which of the following would be the definitive clinical intervention? A. Intra-aortic balloon counterpulsation B. Mitral valve replacement C. Coronary artery bypass surgery D. Immediate fluid bolus

(u) A. Although part of the primary treatment to reduce mitral regurgitation, it is not definitive. (c) B. MVR is the definitive intervention to correct MR caused by papillary muscle rupture. (u) C. CABG may be necessary if significant blockage is found, but it will not correct the mitral regurgitation. (u) D. A fluid bolus is indicated if the patient is hypotensive.

Which of the following is the first complication seen with mitral stenosis? A. Aortic regurgitation B. Aortic stenosis C. Left ventricular failure D. Right ventricular failure

(u) A. Aortic regurgitation results in a volume overload rather than a pressure overload in the left ventricle along with a rapid rise and rapid fall in the peripheral pulse. (u) B. Aortic stenosis causes left ventricular pressure overload due to the narrowed aortic valve interfering with blood getting into the peripheral circulation. The left ventricle and cardiac output and not the mitral valve are primarily affected by aortic stenosis. (u) C. Blood backing up into the atrium results in problems with the right atrium, the pulmonary vasculature, and the right ventricle - it does not result in damage to the left ventricle. (c) D. In long standing, severe MS, patients may develop elevated right-sided pressures and right ventricular dysfunction due to blood backing up from the left atrium. These patients can present with signs and symptoms of right-sided heart failure such as peripheral edema.

On a routine neonate examination, a grade IV/VI holosystolic murmur is heard in the 3rd-4th left intercostal space in the parasternal line. The murmur is most likely that of A. atrial septal defect. B. ventricular septal defect. C. patent ductus arteriosus. D. mitral stenosis.

(u) A. Atrial septal defect will cause fixed splitting of the S2 heart sound as its dramatic auscultatory finding. (c) B. Ventricular septal defect does cause a holosystolic murmur with blood flowing primarily from the left to the right side during systole. (u) C. Patent ductus arteriosus causes a continuous machinery-like murmur from blood flowing through this structure that failed to close after birth. (u) D. Mitral stenosis causes an opening snap and is a diastolic, not systolic, heart murmur.