Adult Cases : Heart Auscultation Quiz
Adult Case 3
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50 year old woman, episode of possible rheumatic fever with rash and arthralgia when she was a teenager. Used to be a jogger; now an active walker but is mildly short of breath going up hills. This appears to be a bit more noticeable in the last year. No other cardiac symptoms. On examination she appears well and weighs about 50 Kg for a BMI of 24. You find her heart action normal and apex beat not displaced. BP 125/80.Pulses are normal. You listen to her heart at the apex.
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3.1 Her heart rate is: a) normal for age
3.2S2: d) single
3.3Systole: a) no murmur or extra sounds
3.4Diastole: e) opening snap and mid-late diastolic murmur
3.5Diagnosis: d) Mitral stenosis
This patient has mitral stenosis of mild to moderate degree, with a gradient which is increasing, accounting for her increasing breathlessness on exertion. Rheumatic carditis in her past is likely the cause. Patients with definite signs of rheumatic fever with arthritis may develop significant mitral valve disease 10-40 years later, according to the Toronto experience, even if the initial carditis is mild. Mitral stenosis is more common than isolated mitral insufficiency.
The auscultation findings of an opening snap, quite loud in her case, and a late diastolic murmur (or “presystolic” as it has been called as it occurs immediately before S1, almost slurring into it), are typical of mitral stenosis. A pansystolic murmur of mitral insufficiency may be heard in some patients but not in her case. The cadence of sounds here is challenging; it could be mimicked as :”whoop, da da”. The whoop is in diastole. It runs into S1, followed in quick succession by S2 and the opening snap. The second heart sound is normally single at the apex but it would be important to listen carefully at the left upper sternal edge where the S2 split can be heard, to assess P2 for possible increased intensity from pulmonary hypertension caused by the mitral stenosis.
Here is the same lesion in a teenager:
Systolic murmur of mitral regurgitation:
Presystolic murmur and snap:
(the last is half speed of the previous)
Her heart rate is:Correct
Your assessment of this patient’s heart:Correct
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