Adult Cases : Heart Auscultation Quiz
Adult Case 6
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30 year old female. Referred for assessment of heart murmur, recently discovered. She is generally well but not particularly active. No symptoms climbing stairs or walking up hills. No regular exercise. She occasionally feels brief episodes of palpitations for a few seconds which are noticeable but only on two occasions did she feel a bit dizzy. She can identify no triggers for these. She only drinks one cup of coffee daily and does not use energy drinks. Alcohol consumption is limited to a glass of wine maybe once a week. She uses no regular medication. She has a female partner with whom she has a very good relationship for over six years. She works as a secretary in a corporate office which is occasionally stressful. Family cardiovascular history is negative.
On examination she appears healthy and quite slim with a BMI of 20. There are no dysmorphic features. Her heart action is easily felt, but the apex is not displaced. Peripheral pulses are normal. BP 110/80. You listen carefully throughout the precordium and especially at the apex
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6.1 S2 d) Single
6.2 Systole d) late systolic murmur with mid systolic click
6.3 Diastole a) normal
6.4 Assessment e) mitral insufficiency with mitral prolapse
This patient has mitral valve prolapse with probably mild mitral insufficiency. The murmur is late systolic and is accompanied by an intermittent mid systolic click. The click and murmur may be more evident in the upright position, as the left ventricle is smaller and afterload is greater, exaggerating the prolapse. (Mitral prolapse can be missed on echocardiography in the recumbent position so if it is suspected patients should be scanned upright). She also has occasional palpitations which accompany mitral valve prolapse in some patients. Chest pain may occur without exercise. Her slim body habitus is found in some patients with this diagnosis, but others may show evidence of Marfan syndrome, so dysmorphic features should be sought.
At the present time this patient does not need intervention but should be followed every few years by echocardiography as the prolapse and insufficiency may progress. The palpitations seem manageable without treatment currently but she should be instructed about Valsalva manoeuvers and lying down if she has a prolonged episode. If the palpitations progress further evaluation may be indicated.
An example of a loud honking mitral insufficiency murmur
Your assessment of this patient’s heart:Correct
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