NURS 6512 Week 7 Auscultation Write-Up Example

Exertional Breathlessness and a Systolic Murmur in a 67-Year-Old Man: Heart and Lung Findings Described by Their Properties

Student Name

College of Nursing, Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Instructor Name

Month Day, Year

Exertional Breathlessness and a Systolic Murmur in a 67-Year-Old Man: Heart and Lung Findings Described by Their Properties

Subjective

D.K. is an invented 67-year-old retired machinist; his history and findings belong to no real person. He reports six months of increasing breathlessness when climbing stairs. A year ago he could climb the two flights to his apartment without stopping; he now pauses on the landing. Three weeks ago, carrying groceries up the stairs, he felt lightheaded and had to sit on a step for a minute, though he did not lose consciousness. He describes an occasional tight feeling across the center of his chest on the steepest part of his neighborhood walk, which settles within two minutes of stopping. He sleeps on one pillow, denies waking breathless at night, and has not noticed ankle swelling.

He was told of a "heart murmur" at a pre-operative visit for a hernia repair five years ago but was not referred. He has hypertension and hyperlipidemia, treated with amlodipine 5 mg and atorvastatin 40 mg daily. He smoked a pack a day for 30 years and quit 12 years ago, giving a 30 pack-year history. He recalls no rheumatic fever in childhood. There is no family history of sudden cardiac death or of heart muscle disease. He denies fever, weight loss, cough with sputum, and wheezing at rest.

Objective

Blood pressure is 142/88 in the right arm and 140/86 in the left, seated. Heart rate is 74 and regular, respirations 16, and room-air saturation 96 percent, with a temperature of 98.2 F. He is comfortable at rest and speaks in full sentences. Jugular venous pressure is estimated at 7 cm of water with his trunk raised to 45 degrees. There is no peripheral edema.

Precordium: Inspection and Palpation

No visible heaves or lifts. The apical impulse sits at the left midclavicular line in the fifth interspace, roughly 2 cm across, and sustained through most of systole rather than brief and tapping. A faint systolic thrill is felt at the right second intercostal space.

Auscultation: The Murmur, Property by Property

S1 is normal. A systolic murmur is heard, and each of its properties is recorded separately (Bickley et al., 2021).

Timing: systolic, beginning shortly after S1 and ending before S2, with a crescendo-decrescendo shape whose peak falls in mid to late systole rather than early.

Location: loudest at the right second intercostal space at the upper sternal border.

Radiation: to both carotid arteries, and also audible at the apex.

Intensity: grade 4 of 6, accompanied by the thrill noted on palpation.

Pitch: medium, best heard with the diaphragm.

Quality: harsh.

Response to maneuvers: the murmur becomes softer during the strain phase of the Valsalva maneuver and when the patient moves from squatting to standing, and louder on squatting and on the beat after a pause.

S2 is soft and single; the aortic component cannot be separated from the pulmonic component in expiration or inspiration. No S3 is heard. A soft S4 appears at the apex once he rolls onto his left side. No diastolic murmur is heard at the left sternal border with the patient sitting forward in held expiration.

Findings That Bear on Severity

The carotid upstroke is delayed and reduced in volume on both sides, rising slowly to a late, small peak. Combined with the single soft S2, the sustained apical impulse, the late-peaking murmur, and the thrill, these findings describe a fixed outflow obstruction of significant degree. Etchells et al. (1997) found that a slow carotid upstroke, a reduced or absent second sound, and a murmur radiating to the right carotid each increased the likelihood of moderate to severe aortic stenosis, which is why they are recorded rather than assumed.

Lungs

Chest expansion is symmetric. Percussion is resonant throughout. Breath sounds are vesicular in all fields, slightly diminished at both bases. On forced expiration there is a faint, high-pitched end-expiratory wheeze at both bases posteriorly. No crackles are heard in inspiration at either base, and none develop after the patient coughs. Egophony is absent. There is no digital clubbing.

Peripheral Findings

Radial, femoral, dorsalis pedis, and posterior tibial pulses are present and symmetric, each small in volume and slow to rise at the radial, matching the carotids. Capillary refill is under two seconds in the fingers and toes. The skin of the lower legs is warm without trophic change. The abdomen is soft, with no hepatomegaly and no pulsatile mass above the umbilicus. There is no sacral or pedal edema, which fits the absent orthopnea and the normal jugular venous pressure: whatever is limiting him on the stairs has not yet produced signs of congestion at rest.

Assessment: The Differential as a Test

Each candidate predicts a pattern of findings, and the recorded properties either match or contradict it.

1. Aortic stenosis. Predicts a harsh, crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids, softer with Valsalva, a soft or single S2, and a delayed carotid upstroke. Every prediction matches. The late peak and the absent A2 suggest severe rather than mild disease, and his three exertional symptoms, breathlessness, chest tightness, and presyncope, are the classic markers of symptomatic stenosis, which carries a poor prognosis without valve intervention (Otto et al., 2021).

2. Hypertrophic cardiomyopathy with outflow obstruction. Predicts a systolic murmur at the left sternal border that grows louder with Valsalva and standing and a brisk, sometimes bifid carotid pulse. The murmur softened with Valsalva and standing, the carotid upstroke is slow rather than brisk, and the murmur radiates to the carotids. The maneuver response and the pulse contradict this candidate.

3. Mitral regurgitation. Predicts a holosystolic, blowing murmur at the apex radiating to the axilla, unchanged by inspiration, with a normal carotid upstroke. The murmur here is crescendo-decrescendo, harsh, and maximal at the base; its apical component is best explained as transmission from the aortic area, a pattern described in older patients with calcific stenosis.

4. Aortic sclerosis or a flow murmur. Predicts a soft, early-peaking murmur of grade 2 or less without a thrill, a normal S2, and a normal carotid upstroke. The grade 4 intensity, the thrill, and the abnormal S2 and pulse contradict it.

5. Chronic obstructive pulmonary disease. Predicts exertional breathlessness in a former heavy smoker, with diminished breath sounds and expiratory wheeze. His smoking history and faint forced expiratory wheeze partly fit, and lung disease may be contributing, but it would not explain the murmur, the pulse, the presyncope, or the chest tightness.

The single finding that best separates the top two candidates is the response of the murmur to the Valsalva maneuver, supported by the carotid upstroke: a murmur that softens with Valsalva and a slow upstroke point to fixed valvular obstruction rather than a dynamic one. Transthoracic echocardiography is the next step to confirm the lesion and grade its severity, and spirometry would clarify how much of his breathlessness belongs to his lungs. Because presyncope on exertion is present, he is advised to avoid strenuous exertion until the echocardiogram is reviewed, and cardiology referral is made at the same visit. He is also taught what to watch for while he waits: fainting or near fainting, chest tightness that comes on at rest or lasts longer than a few minutes, and breathlessness lying flat, each of which should bring him to the emergency department rather than back to the clinic. His amlodipine is continued for now, with the note that vasodilator doses may need review once the valve is graded, since a fixed obstruction limits how much the heart can compensate for a fall in afterload.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

Etchells, E., Bell, C., & Robb, K. (1997). Does this patient have an abnormal systolic murmur? JAMA, 277(7), 564-571. https://doi.org/10.1001/jama.1997.03540310062036

Otto, C. M., Nishimura, R. A., Bonow, R. O., Carabello, B. A., Erwin, J. P., III, Gentile, F., Jneid, H., Krieger, E. V., Mack, M., McLeod, C., O'Gara, P. T., Rigolin, V. H., Sundt, T. M., III, Thompson, A., & Toly, C. (2021). 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 143(5), e72-e227. https://doi.org/10.1161/CIR.0000000000000923