The advanced practice registered nurse (APRN) is performing a cardiovascular exam on a 75 year-old patient. The APRN auscultates a carotid bruit. Which condition is least likely to cause a carotid bruit?

A. Murmur intensity decreases with sitting is correct because innocent (or physiologic) murmurs often become softer or disappear when the patient sits upright. This helps differentiate them from pathologic murmurs, which may remain unchanged or become louder with positional changes.

B. Normal splitting of S2 with inspiration is correct because physiologic splitting of the second heart sound is a normal finding and is consistent with a healthy cardiac examination. An innocent murmur is typically not associated with abnormal heart sounds.

C. Absence of a diastolic murmur is correct because innocent murmurs are exclusively systolic. The presence of a diastolic murmur would suggest a pathologic valvular lesion, such as aortic or mitral regurgitation, rather than an innocent murmur.

D. Murmur intensity increases with sitting is incorrect because an increase in murmur intensity with sitting or standing is more consistent with pathologic conditions, such as hypertrophic cardiomyopathy, rather than a benign or innocent murmur.

A. Bilateral tympanic membranes erythematous, flat, with good cone of light is incorrect because, although erythema is present, the TM is flat, landmarks are intact, and the cone of light is visible, which suggests no middle ear effusion and does not meet criteria for AOM. This may indicate mild irritation, viral upper respiratory infection, or early inflammation.

B. Left tympanic membrane erythematous, bulging and non-mobile, with loss of landmarks is correct because these findings reflect the classic presentation of acute otitis media. Bulging occurs due to pressure from pus or fluid in the middle ear, and non-mobility on pneumatic testing confirms the presence of middle ear effusion, which differentiates AOM from viral pharyngitis or external ear infections.

C. Bilateral tympanic membranes intact and mobile, with good cone of light is incorrect because these are normal otoscopic findings, indicating no acute infection, normal TM integrity, and proper mobility.

D. Right tympanic membrane erythematous and flat, with blood-tinged discharge is incorrect because the blood-tinged discharge suggests trauma, tympanic membrane perforation, or chronic otitis media with perforation, rather than typical AOM. While erythema is consistent with inflammation, the presence of discharge and flat TM points to a different pathology.