NU-664B Week 5 Assignment 2: Cardiac Annotated Study Guide

Week 5 Assignment 2: Cardiac Annotated Study Guide

Due: Sunday, 5 February 2023, 11:55 PM

Done: Make a submission

Value: Complete/Incomplete (100 points is Complete and 0 is Incomplete)

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Due: Day 7

Grading Category: Other Assignments


In this assignment, you will complete the following Annotated Study Guide. The study guide is based on the content from this module and is to be completed as you go through your learning material for this module.

It is strongly suggested that you complete this assignment to better prepare for upcoming assignments and exams. This tool will make a handy reference as you go forward in your practice and career.


  1. Download the Cardiac Annotated Study Guide (Word) before you begin your week’s assigned geriatric assessment assigned readings.
  2. Review the study guide for topics that will be of particular importance during your reading, and type notes from your reading into the guide to annotate it.
  3. Save your final file with your name and assignment title, then follow the instructions to submit your study guide file.
  4. Use this study guide for yourself to study for the course exams and to review for your boards.

Please refer to the Grading Rubric for details on how this activity will be graded.

To Submit Your Assignment:

  1. Select the Add Submissions button.
  2. Drag or upload your files to the File Picker.
  3. Select Save Changes.

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Last modifiedFriday, 3 February 2023, 12:37 PM
File submissionsCardiac Murmus.docxCardiac Murmus.docxTurnitin ID: 2005641044Turnitin ID: 200564104443%GradeMark3 February 2023, 12:37 PM
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Annotated Study Guide for Cardiac Murmurs


Each of the cardiac topics you are responsible for knowing have been collected in the readings for the module and study guide. To help recall and master this material, you will annotate each topic in this study guide with notes, thoughts, and/or images as you perform the required readings at the start of this week. There will be prompts, but do not consider yourself constrained by these, as long as each topic is annotated in some way.

Cardiac Murmurs


  • Heard longer than heart sounds
  • Palpate the carotid arterial pulse
  • Systolic, diastolic, or continuous

Intensity of Sound

  • Crescendo grows louder, decrescendo gets softer, crescendo-decrescendo, plateau


  • Where does the sound originate from?
  • Listen to all areas- aortic, pulmonic, tricuspid, mitral


  • Where does the sound radiate to?
  • Think about direction of the blood flow


  • Graded from I to VI
  • Grade I – very faint
  • Grade II- faint but heart immediately, louder than grade II
  • Grade III- Moderately loud
  • Grade IV- loud, thrill
  • Grade V- heard with stethoscope partly off chest, thrill
  • Grace VI- heard with stethoscope off chest, thrill
  • Loud murmurs can have a thrill


  • What does it sound like- high, medium, low


  • Musical, blowing, harsh, clicking, blowing

Position & Maneuvers

  • Is there a change with position- sitting
  • Is there a change with respiration
  • Valsalva or standing will decrease murmurs except for hypertrophic cardiomyopathy & mitral valve prolapse

Extra Sounds

  • S3 is associated with CHF
  • S4 is associated with LVH

Systolic Murmurs

  • Mitral regurgitation, aortic stenosis
  • Benign murmurs

Mitral Regurgitation

Aortic Stenosis

  • Heard at 2nd ICS right side of the sternum
  • Radiates to neck
  • Harsh & noisy murmur
  • Mid-systolic ejection murmur

Diastolic Murmurs

  • Mitral stenosis, aortic regurgitation
  • Diastolic murmurs are abnormal

Mitral Stenosis

  • Heard at the apex
  • Low pitch rumbling murmur
  • Opening snap
  • Little radiation
  • Can be caused by rheumatic heart disease

Aortic Regurgitation

  • Heard at 2nd ICS right of sternum
  • High pitched blowing murmur, decrescendo

Mitral Valve Prolapse

  • S2 click followed by a systolic murmur
  • Loud & musical
  • May be at higher risk for embolism, TIA, AF
  • Diagnosed with echo & Doppler

Continuous Murmurs

  • Begin during systole and continue into diastole
  • Pericardial friction rub- scratching / scraping
  • Patent Ductus Arteriosis (PDA)- machinery like, harsh
  • Mammary souffle- heard during late 3rd trimester / lactation
  • Where will you expect to hear mitral valve prolapse?
  • Describe the sounds of aortic stenosis.
  • Name 2 systolic murmurs.
  • Name 2 diastolic murmurs.
  • What is the most common murmur?
  • What is the expected location to hear mitral regurgitation?


Match the intensity of the murmur to the Grade

Head with stethoscope not touching chest, thrill present                               Grade II

Loud, accompanied by a thrill                                                                        Grade VI

Very faint, not heard if the person changes position                                      Grade I

Usually readily heard, slightly louder, heard in all positions                         Grade III

Loud but not accompanied by a thrill                                                            Grade IV

Can be heard with stethoscope barely on chest, thrill present                       Grade V

Four Differential Diagnosis:

1.     Community Acquired Pneumonia (CAP) – pneumonia is defined as an acute inflammation of the parenchyma of the lungs and most often is of an infectious origin. Community acquired pneumonia refers to pneumonia that is acquired outside of the hospital setting (Dunphy, 2019). The patient in this case is exhibiting some of the most common symptoms of community acquired pneumonia, including cough, shortness of breath, and pleuritic pain. Additionally, the patient has systemic symptoms of fever which is quite typical and anorexia which may also occur (Ramirez, 2022). This patient also has many of the risk factors for developing CAP such as being over age 65, being exposed to secondhand smoke, living in crowded conditions and having the comorbidity of asthma (Ramirez, 2022). The patient is also having night sweats and reports a rusty colored sputum which makes me think this CAP is bacterial in nature.

2.     Bronchitis – cough lasting at least 1-3 weeks is the primary presenting symptom of patients with bronchitis. Additionally, bronchitis is frequently preceded by a viral upper respiratory infection such as influenza (File, 2022). While it is not clear in this case if the patient had any URI symptoms that preceded her current cough, it is notable that she had exposure to children who were sick with influenza as well as other who were sick with Covid -19. Some of the same factors that put this patient at risk for pneumonia also place her at risk for bronchitis especially her comorbidity of asthma (NIH, 2022). I do feel that this is less likely than the diagnosis of CAP due to her presentation with fever, sweats and anorexia with weight loss (Weinburger, 2022).

3.     Influenza- The patients’ presentation of fever, chills and sore throat (Dunphy, 2019) are part of the classic presentation of the influenza virus. Additionally subjective information reveals that the patient did have exposure to her grandchildren that had influenza about a week ago which does coincide with the patients’ onset of symptoms. The patients rust colored sputum, pleuritic pain and anorexia make this a less likely diagnosis but due to positive exposure, can remain on the differential.

4.     Covid -19 – this must be in the differential because the patient’s daughter had Covid-19 two weeks ago. The patient started having symptoms one week ago. While the incubation period can be up to 14 days after exposure, most cases occur within 4-5 days (McIntosh, 2022). The patients older age, and asthma place her at greater risk for complications of covid such as pneumonia which remains the main diagnosis on the differential list.


Community Acquired Pneumonia (suspected bacterial etiology – s.pneumoniae)


·      Serum CBC, CMP

·      Xray: Chest PA and Lateral

·      Urine: UA/C&S (due to elderly patients’ presentation of fever, anorexia, nausea) (Ramirez, 2022).

·      PCR testing: Covid-19

Pharmacological TX:

·      Amoxicillin-Clavulanate 875mg – take one tablet by mouth twice daily x 5 days

·      Azithromycin – 250 mg – take 2 tablets by mouth today and then take 1 tablet by mouth days 2-6

·      Ibuprofen 200 mg – take 2 tablets by mouth every 8 hours as needed for fever or pain

·      Tylenol 325 mg – take 2 tablets by mouth every 4 hours as needed for fever or pain

·      Albuterol HFA (90mcg) – inhale two puffs with spacer four times daily as needed for cough, SOB, wheeze.

Non-pharmacologic TX:

·      Get plenty of rest

·      Increase fluid intake (stay hydrated) ice pops, jello, broth

·      Drink warm liquids to help loosen phlegm

·      Steam/shower

Referrals: No referrals are needed at this time.

Patient Education:

·      Take your prescription medication and over the counter medications as prescribed. Do not stop taking your antibiotics until they are gone even if you are feeling better.

·      Do NOT take over the counter cough suppressants. This will prevent your body from removing the mucus from your lungs.

·      If you are being kept awake at night by your cough, please contact the office

·      To help keep your lungs clear be sure to turn/reposition yourself when resting in bed at least every hour while you are awake.

·      Practice deep breathing –  every hour take five to 10 deep breaths –  this will help clear your lungs of mucus.

·      Do not drink alcohol

·      Do not smoke and avoid secondhand smoke exposure.

·      Get a lot of rest, including at least 8 hours of sleep at night

·      Sleep with your head elevated at night. Place a few pillows under your head or in a recliner if one is available

·      Increase your fluid consumption. Your urine should be pale yellow. Drinking more fluids will help thin the secretions in your lungs.

·      For sore throat, gargle with a warm saltwater mixture 3-4 times daily

·      Be sure to practice good hand hygiene to prevent the spread of illness to others

·      Wet your hands and put soap on them

·      Rub your hands together for at least 20 seconds. Make sure to clean your wrists, fingernails, and in between your fingers.

·      Rinse your hands

·      Dry your hands with a paper towel and throw away.

Follow up: 48 hour follow up appointment

Prevention: In the United States, vaccines can help prevent infection by some of the bacteria and viruses that can cause pneumonia. Vaccination against influenza and pneumonia are paramount to prevention of pneumonia. Flu vaccination should be done annually. You are over 65 years old and have not been vaccinated against pneumonia. ACIP recommendations indicate you should be vaccinated one time with the Prevnar 20 vaccination.

Social Determinant:

Undocumented immigrants are far more likely to avoid seeking health care due to fears of deportation, lack of financial resources and health insurance, and language barriers. Fears of immigration enforcement has led to greater incidence of infectious diseases among immigrant communities which also presents as a threat to public health. As health care providers it is imperative that we recognize the barriers that undocumented immigrants face when it comes to accessing care. Health care providers can help mitigate fears in these patients by practicing with compassion and providing “Know Your Rights” materials and identifying immigration attorneys in the area (Stutz, 2019).


Bronchitis (2022). NHI. Retrieved from

Chang C. D. (2019). Social Determinants of Health and Health Disparities Among Immigrants and their Children. Current problems in pediatric and adolescent health care49(1), 23–30.

File, T. (2022).Acute bronchitis in adults. Up to Date. Retrieved From

McIntosh, K. (2022)COVID-19: Clinical features. Up to Date. Retrieved From

Ramirez, J. (2022). Overview of Community Acquired Pneumonia in Adults. Up to Date. Retrieved From

Stutz, M., Rivas-Lopez, V., Lonquich, B., & Baig, A. A. (2019). Health Repercussions of a Culture of Fear Within Undocumented Immigrant Communities. Journal of General Internal Medicine34(9), 1903–1905.

Weinberger, S. (2022). Evaluation and treatment of subacute and chronic cough in adults. Up to Date. Retrieved From

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