Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.   

A 35-year-old woman presents for a well-woman exam. She's without complaint, BMI is 22 and reports that she runs about 28 miles a week, 4-5 miles with each run, and has excellent exercise tolerance. She states, “I'm in really great health.” On physical exam, the NP notes a faint mid-systolic click followed by a grade 2/6 mid-late systolic murmur best heard at the apex. No other abnormalities are noted. These findings are most suggestive of:

Aortic stenosis.
Mitral stenosis.
Mitral regurgitation.
Mitral valve prolapse.

The correct answer is D. Mitral valve prolapse. Where do you start? Consider what kind of a question this is. We have been given information on the health history and the physical exam and then asked, what could this represent? Therefore, this is a diagnosis question.

Let's take a look at some background information. Heart murmurs are caused by sounds produced from turbulent blood flow. Blood traveling through the chambers and great vessels of the heart is usually silent. When the blood flow is sufficient to generate turbulence in the wall of the heart or great vessel, a murmur occurs. In particular, systolic heart murmurs are often benign, implying no significant cardiac abnormality is contributing to the murmur’s generation.

Indeed, in a person like her: younger, healthier, great BMI, since the chest wall is thinner, we're probably going to pick up a lot more murmurs, including absolutely benign murmurs. In a person with a higher BMI, often the thicker chest wall can obstruct a cardiac murmur, even one that’s 100% benign. In this case scenario, we're provided with albeit limited information on the patient, including a crucial part of any cardiac exam, and that's the report of exercise tolerance. Here, it's reported as being outstanding. And by the way, I want you to remember this for the boards: if you are given information about health history, patient report of symptoms, or a lack thereof, or physical exam, assume everything you're being told about this patient is accurate. With certain pathologic cardiac murmurs, symptoms of low cardiac output, including activity intolerance, are often reported.

And remember, she's a runner, 4 to 5 miles at a time. Great tolerance. So that leans towards this being something non-pathologic. Mitral valve prolapse, of course, is the correct answer here and is likely the most common valvular heart issue, estimated to be actually up to about 10% of the general population. So, why is it we don't run into one in ten people having the murmur of mitral regurg?

Part of this is because of some of the factors I mentioned before: thick chest wall, and higher BMI. So much of picking up murmurs is, quite frankly, the skill of the examiner. Most people with MVP, mitral valve prolapse, have a benign condition in which one of the valve leaflets is unusually long and buckles or prolapses into the left atrium, usually mid-systolic. At that time a click occurs that is followed by a short murmur caused by the regurgitation of just a wee bit of blood into the left atrium. Cardiac output is usually uncompromised and the event goes unnoticed by the patient. However, the clinician might pick up the murmur on the exam. A very small percentage of people with mitral valve prolapse have valve thickening and redundancy with clinically significant mitral regurgitation.

This group often has additional health challenges, such as Marfan syndrome or other connective tissue disorders. Given that no other health problems are mentioned in this clinical scenario and her exercise tolerance is excellent, we can push the thought that she has mitral valve prolapse disease to one side. Benign mitral valve prolapse is characterized by an echocardiographic finding that failed to reveal any other abnormalities in simply noticing this valve buckling followed by a small volume mitral regurgitation.

If there are no cardiac complaints and the rest of the cardiac exam, including ECG, is normal, no further evaluation is needed. Barring other health problems, patients with mitral valve prolapse usually have normal cardiac output and tolerate a program of aerobic activity, which this patient clearly does. With that in mind, let's take a look at the questions and answers.

I do want you to keep in mind and you just might be tired of hearing me say this since we're so many podcasts into this, but always think-- what groups are given health issue found in? This is a clinical concept I encourage you to remember throughout these podcasts. So, let's go dive into this question.

A 35-year-old woman presents for a well-woman exam. She's without complaint with a BMI of 22 and reports that she runs about 28 miles a week 4-5 miles with each run, and has excellent exercise tolerance. She states, “I'm in really great health.” On physical exam, the NP notes a faint mid-systolic click followed by a grade 2/6 mid-late systolic murmur best heard at the apex. No other abnormalities are noted. These findings are suggestive of:

Aortic stenosis. This is incorrect. Aortic stenosis, often abbreviated AS is the inability of the aortic valve to open to an optimal orifice. Well, while the murmur of aortic stenosis is systolic, it is usually heard as a grade 1 through 4/6 harsh systolic murmur. Most commonly, it's going to be grade 2 to 3, in part because grade 1 murmurs are just so hard to hear. Usually in a crescendo-decrescendo pattern heard best at the second right intercostal space, usually with radiation up into the neck. The reason the murmur radiates to the neck is the murmur is generated by turbulence of blood flow around the aortic valve. And then once the blood goes over the aortic valve, where does it go next? It goes up into the carotids. In addition, the most common reason for aortic stenosis is aortic calcification. Therefore, it's noted in patients of advanced age, particularly with higher cardiovascular risk, including longstanding, poorly controlled hypertension. Those are factors that are simply not noted in this particular patient. Usually, by the time a person presents with aortic stenosis, they will have some kind of symptoms of reduced cardiac output, including activity intolerance. That is clearly not noted here. So, to recap, because of her age, her great activity tolerance, and certainly her lack of risk for aortic stenosis, and that her murmur doesn't sound like the murmur of aortic stenosis we’re pushing that to one side.
Mitral stenosis. This is also not correct, but this is a diastolic murmur. So, you could have eliminated this very quickly. Presenting as a low diastolic rumble, this murmur is usually only heard with significant cardiac pathology, often with a history of rheumatic heart disease, and with a patient report of activity intolerance. And are you getting the feeling that including information about how well a person tolerates activity or does not is important to a thorough cardiac history? Yes, you get that. And I would add one other point. Make sure you compare it to what is their typical baseline, and how physically active they are.
Mitral regurgitation. Mitral regurg, commonly abbreviated MR, results in a grade 1 to 4/6 high-pitched blowing systolic murmur. The murmur is often reported as sounding like hahaha or whoowhoowhoowhoo. It's heard best at the left lower sternal border and tends to radiate to the axilla. So again, keep in mind the risk for this condition in this scenario, the person is younger and we're told in good health. Mitral regurgitation is most commonly noted in the presence of ischemic heart disease, acute endocarditis, rheumatic heart disease, and with a report of lower cardiac output symptoms.

D. Of course, mitral valve prolapse is our correct answer. The murmur of MVP is most often noted in an otherwise well person without low cardiac output symptoms as is reported here. The next step test, of course, should include getting an echocardiogram to confirm this finding.

Key takeaway: As an NP, you were charged with initiating the diagnostic evaluation. When you find an abnormality on the cardiac exam, knowing which murmurs occur, in which patient groups, and whether symptoms are present or not, is critical to NP practice.

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