The nurse finds the apical pulse below the 5th intercostal space. The nurse suspects:
A. Left atrial enlargement
B. Left ventricular enlargement
C. Right atrial enlargement
D. Right ventricular enlargement
Correct Answer: B. Left ventricular enlargement
A normal apical impulse is found under over the apex of the heart and is typically located and auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular enlargement.
Option A: Left atrial enlargement (LAE) is the hallmark of the structural remodeling process, which occurs in response to chronic pressure and volume overload. LAE occurs most commonly in association with diastolic dysfunction, left ventricular hypertrophy, mitral valvular disease, and systemic hypertension. Patients with LAE might present with a variety of symptoms, including palpitations, dyspnea, syncope, peripheral edema, fatigue, and weight gain.
Option C: When right atrial enlargement occurs, it does not take longer for cardiac action potentials to travel through the atrial myocardium (similar to left atrial enlargement). However, the amplitude of the P wave is exaggerated due to the close proximity of the hypertrophied right atrial myocardium to the SA node.
Option D: Right ventricular hypertrophy (RVH) is an abnormal enlargement or pathologic increase in muscle mass of the right ventricle in response to pressure overload, most commonly due to severe lung disease. The right ventricle is considerably smaller than the left ventricle and produces electrical forces that are largely obscured by those generated by the larger left ventricle. The most prominent features of the physical examination in patients with TR are those related to the regurgitant murmur and the development of right-sided heart failure.
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