A 23-year-old woman comes to the office due to exertional dyspnea. She occasionally has a dry cough but has had no chest pain, palpitations, or syncope. The patient emigrated from Cambodia 3 years ago. She had bilateral knee swelling as a child. Cardiac auscultation findings over the cardiac apex are given below. Which of the following is the most likely cause of this patient's symptoms?

Question

A 23-year-old woman comes to the office due to exertional dyspnea.  She occasionally has a dry cough but has had no chest pain, palpitations, or syncope.  The patient emigrated from Cambodia 3 years ago.  She had bilateral knee swelling as a child.  Cardiac auscultation findings over the cardiac apex are given below.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_3a92_c07f_9249_1ba68e15e257_MD0001_00 This patient's auscultatory findings reveal a blowing holosystolic murmur best heard over the cardiac apex (typically with radiation to the axilla), which is classic for mitral regurgitation (MR). Given her emigration from Southeast Asia and knee swelling as a child, the MR is most likely due to rheumatic heart disease (rheumatic heart disease is most commonly seen in Latin America, Africa, and Asia). Patients with rheumatic heart disease almost always have mitral valve involvement; MR is the more common manifestation in young patients (eg, age <25), whereas mitral stenosis is more common in middle-aged patients (eg, age >30). With increasing age, mixed mitral valve disease (ie, components of both regurgitation and stenosis) becomes increasingly frequent. (Choice A) Patients with an ascending aortic aneurysm may develop aortic regurgitation secondary to aortic root dilation; an early decrescendo diastolic murmur is expected, best heard at the right upper sternal border. (Choice B) The typical murmur of an atrial septal defect is not caused by blood flow through the defect itself but results from an elevation in right-sided blood volume with increased blood flow across the pulmonic valve (ie, pulmonic flow murmur). It is recognized as a faint midsystolic murmur best heard at the left upper sternal border and with fixed splitting of S2. (Choice C) A bicuspid aortic valve is commonly associated with aortic stenosis, which classically causes a crescendo-decrescendo systolic murmur best heard at the right upper sternal border and with radiation to the carotids. Aortic stenosis due to a bicuspid aortic valve typically affects patients age >40. (Choice E) Rheumatic heart disease is the most common cause of mitral stenosis. With mitral stenosis, auscultation at the cardiac apex is expected to reveal an opening snap followed by a low-pitch, middiastolic, rumbling murmur. The murmur may accentuate in late diastole due to atrial contraction against the stenotic valve. Educational objective: Mitral regurgitation causes a blowing holosystolic murmur best heard at the cardiac apex and with radiation to the axilla. Rheumatic heart disease is a common cause of both mitral regurgitation and mitral stenosis and is most commonly seen in patients who grew up in Latin America, Africa, or Asia.

A 23-Year-Old Woman Comes to the Office Due to Exertional