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A 66-year-old woman presents with a sensation of pulsation in her neck and abdomen. The patient reports she has also had progressively worsening dyspnea on exertion and peripheral edema that began 2 months ago. She had a pacemaker placement 9 months ago for a chronic bifascicular block. Physical exam is significant for distended, pulsatile neck veins, hepatomegaly, and 1+ generalized pitting edema. Palpation of the liver results in increased distension of the neck veins. Which of the following findings on physical exam would most likely correlate with the patient’s condition?

A Harsh midsystolic crescendo-decrescendo murmur radiating to the left shoulder
B Loud midsystolic murmur best heard with the patient sitting and leaning forward
C Pansystolic murmur that becomes louder with inspiration
D Pansystolic murmur with prolonged apical impulse

Tricuspid regurgitation is a valvular disorder that occurs when there is retrograde blood flow from the right ventricle to the right atrium during systole. The underlying pathophysiology is a right-sided pressure overload leading to right-sided heart failure. Common causes of tricuspid regurgitation include congenital abnormalities of the tricuspid valve, structural abnormalities resulting from infection, and chronic pulmonary hypertension. Pacemaker lead placement is an increasingly common iatrogenic cause of tricuspid regurgitation. As tricuspid regurgitation persists, right-sided cardiomegaly, systemic venous congestion, and eventually right-sided heart failure ensue. Signs of severe tricuspid regurgitation are associated with systemic venous congestion and include distended, pulsating neck veins, a pulsatile enlarged liver, and anasarca. On cardiac auscultation, tricuspid regurgitation is a pansystolic murmur that becomes louder with inspiration and reduced with expiration or Valsalva maneuver. It is best heard at the left lower sternal border and radiates to the right lower sternal border. Chest radiography may show an enlarged right heart border. ECG findings include right-axis deviation, P wave changes indicating right atrial enlargement, and R and S wave changes indicating right ventricular hypertrophy. Definitive diagnostic methods for tricuspid regurgitation include echocardiography and cardiac catheterization. Valvular regurgitations are classified as mild, moderate, or severe based on a variety of measurements obtained from diagnostic measures. Since most cases of tricuspid regurgitation are secondary, treatment of the underlying cause should be considered first. Patients with mild or moderate tricuspid regurgitation may be managed with oral diuretics (e.g., furosemide). Moderate tricuspid regurgitation warrants a cardiology consult. Severe tricuspid regurgitation may require IV diuretics such as torsemide. Spironolactone may be used if ascites is present along with severe tricuspid regurgitation. Severe cases require regular monitoring by a cardiologist. Valvular repair may be indicated in patients with tricuspid valve endocarditis. Patients with refractory symptoms due to inherent defects may need a tricuspid valve replacement.

A harsh midsystolic crescendo-decrescendo murmur radiating to the left shoulder (A) and neck that is best heard at the second to third left intercostal space is associated with pulmonic stenosis. An early pulmonic ejection sound is common. A loud midsystolic murmur best heard with the patient sitting and leaning forward (B) is associated with aortic stenosis. Aortic stenosis is best heard at the second right intercostal space and radiates to the neck and left sternal border. A pansystolic murmur with prolonged apical impulse (D) that is best heard at the apex and radiating to the left axilla is associated with mitral regurgitation.


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tricuspid regurgitation

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Q: What is the Carvallo sign?

Reveal Answer

A: The murmur in tricuspid regurgitation becomes louder with inspiration.

Tricuspid Regurgitation

  • Causes: tricuspid ring stretching > pulmonary HTN, endocarditis, rheumatic heart disease
  • Pansystolic murmur at left (or right) sternal border
  • JVP: giant c-v wave
  • Atrial fibrillation

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Get a little more clarification

When can I take the PANCE?
You must graduate from an accredited program to qualify for the PANCE, and you can apply for the exam anytime within 180 days before your program completion date. The soonest you can take the exam is 7 days after your program completion date.

For more information, read Everything You Need to Know for the PANCE Exam and the Top Questions about Qbanks for PA Students, the PANCE, & Rotation Exams.
How hard is the PANCE?
That’s a subjective question—everyone’s experience is different!

In January 2019, the NCCPA updated the Content Blueprint, which resulted in lower pass rates for first-time test takers. This doesn’t mean the test is harder (just different), so keep studying, and remember that you’ve been preparing since day 1 of PA school.
How many questions are on the PANCE?
There are 300 multiple-choice questions, which you will take in 5 blocks of 60 questions each. You have 60 minutes to complete each block.

The PANCE Qbank contains thousands of questions covering the topics you need to know, so you'll get plenty of practice!
How should I study for the PANCE?
If you found a study routine that worked well during your rotation exams, stick with it! If you're still trying to find your optimal strategy, check out these resources:
Which PA Qbanks should I compare?
These are the companies we suggest trying to make sure you find the Qbank that's right for you. Compare them by signing up for a free trial:
  • BoardVitals
  • Exam Master
  • Hippo Education
  • Kaplan
  • NEJM Knowledge+
  • PAEasy
  • Rosh Review
  • UWorld
How to Select the Best PANCE Review Qbank breaks down the selection criteria you can use.
How many questions are on PA rotation exams?
Each rotation exam has 120 questions.

The seven Rotation Exam Qbanks each contain 250 questions (that's 1,750 questions total for the Qbank bundle), so you'll get plenty of practice for the exam! And if you're ready to go one step further while you prepare, check your Boost Box for additional 120-question Mock Rotation Exams.
How should I study for PA rotation exams?
The most important thing is to find a strategy that works for you and stick with it. Here are some tips to help you focus in on your optimal study routine:
How do I get started?
Whether you have a trial account or you purchased a subscription, access Rosh Review by logging in at To access the Qbank, go to the Create Exam tab to begin making and taking exams made up of questions from the Qbank. You can find any boost exams under the My ExamsBoost Exam tab. Once you've completed and submitted a few exams, you can see your statistics under the Performance Analysis tab.
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