Which of the following conditions would tend to shift the point of maximal impulse (PMI) far-ther to the left?
1. Pulmonary emphysema
2. Collapse of the left lower lobe
3. Collapse of the right lower lobe
4. Right-sided tension pneumothorax
a. 1, 2, and 3 only
b. 2 and 4 only
c. 2, 3, and 4 only
d. 1, 2, 3, and 4
ANS: B
The PMI may shift either left or right, following deviations in the position of the lower medias-tinum, which may be caused by pneumothorax or lobar collapse. Typically, the PMI shifts toward lobar collapse but away from a tension pneumothorax. The PMI in patients with emphysema and low flat diaphragms may be shifted centrally to the epigastric area.
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