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Difficulty: MediumPhysical Examination Findings

A 42-year-old woman, who immigrated to the United States from a resource-limited country 5 years ago, presents to the clinic with a 6-month history of progressively worsening exertional dyspnea, orthopnea, and occasional episodes of hemoptysis. She recalls experiencing a prolonged febrile illness with severe joint swelling during childhood that was never treated with antibiotics. Her vital signs show a blood pressure of 110/70 mmHg and a heart rate of 92/min with an irregularly irregular rhythm. Which of the following physical examination findings are most consistent with the most likely underlying structural cardiac disease in this patient? (Select two)

  1. Loud first heart sound (S1)Answer
  2. Early diastolic opening snap with a low-pitched rumbling murmurAnswer
  3. C
    Holosystolic murmur at the apex radiating to the left axilla
  4. D
    Harsh crescendo-decrescendo systolic murmur at the right upper sternal border
  5. E
    High-pitched, blowing, early diastolic murmur at the left sternal border

Answer

The correct findings are a loud first heart sound (S1) and an early diastolic opening snap with a low-pitched rumbling murmur.
The patient's clinical presentation is classic for severe rheumatic mitral stenosis. The childhood history of untreated febrile illness with joint swelling suggests acute rheumatic fever. The current symptoms of dyspnea, orthopnea, and hemoptysis, along with new-onset atrial fibrillation (indicated by the irregularly irregular rhythm), are typical complications of the resulting left atrial enlargement and elevated pulmonary venous pressures. On physical examination, mitral stenosis is characterized by a loud first heart sound (S1) and an early diastolic opening snap followed by a low-pitched, mid-to-late diastolic rumbling murmur. The loud S1 occurs due to the delayed and forceful closure of the thickened mitral valve leaflets. The opening snap results from the sudden tensing of the stenotic valve as it opens into the left ventricle.

Step-by-Step Solution

1
Identify the likely diagnosis based on the patient's history.
The history of childhood febrile illness with joint swelling suggests acute rheumatic fever. The current symptoms of progressive heart failure, hemoptysis, and an irregularly irregular rhythm (atrial fibrillation) strongly indicate rheumatic mitral stenosis.
Recognizing the classic clinical presentation is essential for predicting the associated physical examination findings.
2
Determine the characteristic auscultatory findings of the identified condition.
Mitral stenosis is characterized by a loud S1, an opening snap in early diastole, and a low-pitched mid-to-late diastolic rumbling murmur.
These findings reflect the abnormal hemodynamics and structural changes of the stenotic mitral valve.

Key Concept

The hallmark physical examination findings of rheumatic mitral stenosis include a loud S1, an early diastolic opening snap, and a mid-to-late diastolic rumbling murmur.
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Physical Examination Findings

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