Question

Chief Complaint: 74-year-old woman with shortness of breath and swelling.

History: Martha Wilmington, a 74-year-old woman with a history of rheumatic fever while in her twenties, presented to her physician with complaints of increasing shortness of breath ("dyspnea") upon exertion. She also noted that the typical swelling she's had in her ankles for years has started to get worse over the past two months, making it especially difficult to get her shoes on toward the end of the day. In the past week, she's had a decreased appetite, some nausea and vomiting, and tenderness in the right upper quadrant of the abdomen.

On physical examination, Martha's jugular veins were noticeably distended. Auscultation of the heart revealed a low-pitched, rumbling systolic murmur, heard best over the left upper sternal border. In addition, she had an extra, "S₃" heart sound.

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Questions:

1. What is causing this murmur?

2. What is causing her "S₃" heart sound?

3. Is her history of rheumatic fever relevant to her current symptoms? Explain.

4. A chest X-ray reveals a cardiac silhouette that is normal in diameter. Does this rule out a possible problem with Martha's heart? Explain.

Answer 1

1. The most probable diagnosis for the above patient is Mitral Regurgitation (MR) with Right heart failure.

In mitral regurgitation, there is leakage of blood from left ventricle to left atrium. This turbulent blood flow occurs when the left ventricular pressure increases during systole and thus cause systolic murmur.

2. S3 heart sound is heard in MR. S3 is heard in cases of volume overload conditions. Due to the leakage of blood from left ventricle to left atrium in MR results in increase in amount of blood in left atrium. This extra amount of blood also needs to come back to left ventricle during diastole causing S3.

3.Yes, History of Rheumatic fever is relevant in case of MR. . In rheumatic fever antibodies produced against group A beta hemolytic streptococcus counteract with M protein present in heart.Endocarditis is an important feature of rheumatic fever. Most common valve involved in case of rheumatic fever is mitral valve. It is because of the high pressure differnce across mitral valve. It causes scarring of leaflets of the mitral valve which interrupt with the coaptation of valve. This results in leaking mitral valve.

4.Yes. Cardiomegaly is a common cause of X-ray with enlarged cardiac silhouette.In dilated cardimyopathy, hypertrophic cardimyopathy also presents with dyspnoea, effort intolerance, ankle edema. Systolic murmur is heard in HOCM. S3 is heard in dilated cardimyopathy. In order to exclude these differential diagnosis X ray is helpful.