Adult Cases : Heart Auscultation Quiz

Answers

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

Discussion:
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.

Additional recording:

An example of a loud honking mitral insufficiency murmur

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