Bates Guide to Physical Examination and History Taking, 12th Edition

Bates’ Guide to Physical Examination and History Taking, 12th Edition

Chapter 9: The Cardiovascular System

Multiple Choice

• You are performing a thorough cardiac examination. Which of the following chambers of

the heart can you assess by palpation?

• Left atrium
• Right atrium
• Right ventricle
• Sinus node

Ans: C

Chapter: 09

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?
• Closure of aortic, then pulmonic valves
• Closure of mitral, then tricuspid valves
• Closure of aortic, then tricuspid valves
• Closure of mitral, then pulmonic valves

Ans: A

Chapter: 09

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

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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?

• Mitral
• Tricuspid
• Aortic
• Pulmonic

Ans: A

Chapter: 09

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?

• Abdominal pain
• Orthopnea
• Hematochezia
• Tenesmus

Ans: B

Chapter: 09

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?

• Normal
• Prehypertension
• Stage 1 hypertension

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• Stage 2 hypertension

Ans: B

Chapter: 09

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?

• Ethnicity
• Alcohol intake
• Gender
• Asthma

Ans: C

Chapter: 09

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?

• Hypertension
• Peripheral arterial disease
• Systemic lupus erythematosus
• Chronic obstructive pulmonary disease (COPD)

Ans: B

Chapter: 09

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.

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• 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?

• Palpable
• Soft, rapid, undulating quality
• Pulsation eliminated by light pressure on the vessel
• Level of pulsation changes with changes in position

Ans: A

Chapter: 09

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?

• Left-sided heart failure
• Mitral stenosis
• Constrictive pericarditis
• Aortic aneurysm

Ans: C

Chapter: 09

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?

• Hypothyroidism
• Aortic stenosis, with pressure overload of the left ventricle

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