[Fan Favorite] Cardiac

As we step away for a holiday break, we’re excited to revisit some of the most popular episodes of the FNP Certification Q & A Podcast. These listener favorites have informed, inspired, and empowered aspiring NPs on their journey to certification success. Enjoy some of our favorites. We'll catch you in 2025 with fresh questions from Dr. Fitzgerald!

In evaluating a 66-year-old man with dilated cardiomyopathy and heart failure, the NP notes a grade 3/6 medium-pitched blowing systolic murmur that radiates to the axillae. What do these findings most likely represent?

A.Innocent murmur

B. Mitral stenosis

C. Aortic regurgitation

D. Mitral regurgitation
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Transcript

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.  

 In evaluating a 66-year-old man with dilated cardiomyopathy and heart failure, the NP notes a grade 3/6 medium-pitched blowing systolic murmur that radiates to the axillae. These findings most likely represent:  

1. Innocent murmur 
2. Mitral stenosis 
3. Aortic regurgitation 
4. Mitral regurgitation.  

 Where do you start? 

 First, determine what kind of question this is. This is likely a working diagnosis question based on analysis and synthesis of the patient history and physical exam findings. Conversely, sometimes on the NP boards, it's not as cut and dry as you might think it could be on whether it's an assessment, diagnosis, plan, or evaluation question. And this could be looked at as an assessment question as what we're looking at is a physical exam finding as part of ongoing clinical information gathering. 

 Next, determine the probabilities. Prudent practices dictates that the NP considers how a disease has developed. Dilated cardiomyopathy with resulting heart failure is most often the consequence of longstanding hypertension, particularly in patients whose blood pressure control over the years has been less than optimal. This is often coupled with other atherosclerotic cardiovascular disease risks, including diabetes and dyslipidemia. 

The name of the condition implies its pathology, where the heart chambers in dilated cardiomyopathy, particularly the left ventricle, are enlarged and unable to contract efficiently. The end product is the development of heart failure. 

Keeping all this in mind, what are the physical exam findings, including heart murmurs commonly noted in dilated cardiomyopathy? Let's take a look at the options provided. 

Option A: Innocent murmur. Well, the key word here is innocent. This implies in a heart murmur, that is noted in the absence of cardiac pathology. We are automatically going to reject that as an option because this is an older adult with known cardiac pathology. Innocent murmurs are also known as functional or physiologic murmurs noted in the absence of any cardiac problems. In addition it is characterized by an early onset systolic murmur with both heart sounds intact. What we’re told here, of course, is this is an older adult with a highly abnormal cardiac exam and known cardiac pathology. 

Option B: Mitral stenosis. This condition presents as a diastolic heart murmur, where as the patient we’re talking about in this question has a systolic murmur, and mitral stenosis is nearly always associated with a history of rheumatic heart disease,which is not mentioned in the question. Please keep in mind as you’re looking at exam questions, that critical information about health history or history of present illness will always be included in the board question. 

 Option C: Aortic regurgitation. Aortic regurgitation manifests as an early diastolic murmur that often radiates to the neck. Common reasons for aortic regurgitation (AR) are infective endocarditis and rheumatic heart disease, again not part of this patient's presentation. 

 Option D: Mitral regurgitation. Here we go, here is the correct answer. Mitral valve incompetency, or the failure of the mitral valve to close properly, and its resulting murmur of mitral regurgitation, is characterized by the backflow of blood across the closed mitral valve. Any event that happens when the mitral valve is closed, is a systolic event. Since this murmer is happening in the most muscular chamber of the heart, the left ventricle, the sound generated is a loud one. And keep in mind, murmurs that radiate are generally louder murmurs. Mitral regurgitation is found in patients with dilated cardiomyopathy, heart failure, ischemic heart disease, endocarditis, and rheumatic heart disease. 

 Key takeaway: When caring for a person with an altered cardiac exam, consider the risks associated with each condition that would result in this change and then correlate that with the diseases pathophysiology. Pulling all of these factors together to arrive at the correct diagnosis and the correct answer is critical for NP board success and success in your clinical practice. 

Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com.