Question 201

Question:

A 28-year-old man who had rheumatic fever as a child comes to the physician’s office because of fatigue and dyspnea for the past 4 months. An early diastolic sound followed by a low-pitched rumbling decrescendo diastolic murmur is present 4 cm left of the sternal border in the fourth intercostal space and is heard best with the patient in the left lateral decubitus position. Which of the following valve defects is most likely in this patient?

Correct Answer: D.  Mitral stenosis

Always associate mitral stenosis with rheumatic fever. Other valves can be involved but the most common cause of mitral stenosis is aseptic scarring after systemic Group A Streptococcus infection. The murmur of mitral stenosis is described as above. As with any murmur, as the severity increases so does pressure in the chamber before the valve (in this case the left atrium). Dyspnea, fatigue, and rales on exam are symptoms of congestive heart failure, regardless of the underlying cause. This is also the murmur that may be revealed during pregnancy. Aortic regurgitation is a diastolic murmur characterized by wide pulse pressure and may be associated with aortic dissection or trauma. Aortic stenosis usually occurs in elderly patients secondary to calcifications, but it can also be secondary to congenital bicuspid aortic valve in young people. The aortic stenosis murmur is crescendo decrescendo and radiates to the carotids. Mitral regurgitation murmurs are systolic and can occur secondary to chordae tendinae rupture after MI or in predisposed people with mitral valve prolapse. It is a blowing mid to late systolic murmur. Pulmonic regurgitation is a diastolic murmur best heard in the left 2nd intercostal space usually secondary to congenital defect.