Aligned with the PAEA and NCCPA formats and updated blueprints. Authored & peer-reviewed by PA-Cs who excelled on their rotation exams and the PANCE.
Each question is written to resemble the format and topics on the exam, meaning you won’t see any negatively phrased questions, no “all of the following except,” no “A and B”…you know what we mean. Most importantly, all questions include selective distractors (incorrect answer choices), which will help you think critically.
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?
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.
Understanding why an answer choice is incorrect is just as important as knowing why one is correct. That’s why every Rosh Review question includes detailed explanations for the correct and incorrect answer choices. These comprehensive summaries link the most important components of a topic—from risk factors to diagnostics and treatment—giving you the context to build relationships between them.
Custom illustrations and tables help further clarify the core concepts. When information is presented visually, you can focus on meaning, easily reorganize and group similar ideas, and make better use of your memory.
Your personal analytics allow you to see your progress at all times, so you can create an efficient and effective learning strategy and stay on pace with your plan.
Deep insights to determine your strengths and weaknesses so you can spend your time on the subjects that matter.
Discover how your answer choices align with those selected by learners across the country.
Using data generated by previous users, your Qbank gives a prediction of how likely you are to pass your exam.
After each explanation is a straightforward question with a simple, memorizable answer that reinforces the corresponding topic.
These bulleted reviews focus on condensed, high-yield concepts about the main topic, from patient presentation to preferred management.