BOF: 2.1
A 65-year-old patient presents with a history of
palpitations and breathlessness. She gives a history of Sydenham’s chorea as
a child. On examination she has a pulse rate of 120 beats per minute rhythm;
irregularly irregular, small volume. JVP not elevated, apex beat not
displaced, tapping in nature. There is left parasternal heave, the first and
second heart sounds are loud and there is an opening snap and a low-pitched
rumbling mid-diastolic murmur.
Which of the following physical signs suggest that a
complication of her condition has occurred?
a)
Loud first heart sound
b)
Loud second heart sound
c)
Opening snap
d)
Mid-diastolic murmur
e)
Tapping apex
Answer:
b)
The history and physical signs suggest the patient has
mitral stenosis. The tapping apex beat and loud second sound reflect
thickening of the mitral valve. They are caused by the thickened valve
leaflets not floating up with ventricular filling in diastole and the valves
shutting from a greater distance than normal, thus producing a louder sound.
The opening snap reflects thickening of the valve and its presence also
indicates that the valve is pliable. The mid-diastolic murmur is due to
stenosis of the mitral valve. The loud second heart sound is caused by
pulmonary hypertension and reflects development of this complication of mitral
stenosis.
Mitral Stenosis
