A 55-year-old woman comes to the office due to persistent shortness of breath. Over the last year, she has had difficulty climbing the stairs to her bedroom and performing household chores. The patient also feels fatigued at the end of the day. She has no chest pain, cough, syncope, or lower extremity swelling. Medical history is significant for carpal tunnel syndrome and hypothyroidism, for which she takes levothyroxine. The patient is a lifetime nonsmoker. She has no family history of early coronary artery disease. Blood pressure is 133/75 mm Hg and pulse is 85/min and regular. Lungs are clear on auscultation. The apical impulse is displaced to the left, and there is a palpable systolic thrill. A 4/6 blowing and high-pitched holosystolic murmur is heard at the apex. Which of the following additional physical findings would most likely be present in this patient?

Question

A 55-year-old woman comes to the office due to persistent shortness of breath.  Over the last year, she has had difficulty climbing the stairs to her bedroom and performing household chores.  The patient also feels fatigued at the end of the day.  She has no chest pain, cough, syncope, or lower extremity swelling.  Medical history is significant for carpal tunnel syndrome and hypothyroidism, for which she takes levothyroxine.  The patient is a lifetime nonsmoker.  She has no family history of early coronary artery disease.  Blood pressure is 133/75 mm Hg and pulse is 85/min and regular.  Lungs are clear on auscultation.  The apical impulse is displaced to the left, and there is a palpable systolic thrill.  A 4/6 blowing and high-pitched holosystolic murmur is heard at the apex.  Which of the following additional physical findings would most likely be present in this patient?

Quizplus · Accepted Answer

An intense holosystolic murmur best heard at the cardiac apex is consistent with severe mitral regurgitation (MR). Due to backflow of blood from the left ventricle (LV) to the left atrium during systole, the total amount of blood entering the LV during diastole is increased. To compensate for the increased volume load, the LV undergoes eccentric hypertrophy and LV cavity dilation. Patients initially develop symptoms (eg, dyspnea on exertion) due to decreased cardiac output (the lungs are clear during this time). Further progression can lead to decompensated heart failure with increased left atrial pressure and pulmonary edema. An audible S3 gallop is an expected finding in patients with severe MR. It results from reverberation of the walls of the dilated LV during the passive filling phase of diastole. The S3 is present prior to the development of decompensated heart failure, and the absence of an S3 helps exclude severe chronic MR. An S3 is also commonly heard with decompensated heart failure of any etiology. (Choice A) Finger clubbing can result from chronic hypoxemia, such as occurs in disorders with right-to-left intracardiac shunting (eg, tetralogy of Fallot). MR causes dyspnea due to reduced cardiac output; significant hypoxemia is unlikely unless there is pulmonary edema (this patient's lungs are clear on auscultation). (Choice B) An opening snap occurs with mitral stenosis. It can be appreciated just after S2, as the stenotic mitral valve opens at the beginning of diastole. (Choice D) An S4 is often heard in patients with concentric LV hypertrophy due to systemic hypertension or severe aortic stenosis. It is caused by blood striking a stiff left ventricle during atrial systole, just before mitral valve closure (S1). (Choice E) Uvular pulsation (Müller's sign) may be appreciated with the high-amplitude systolic pulsation and rapid diastolic collapse that occurs with severe aortic regurgitation. (Choice F) Wide and fixed splitting of S2 occurs with an atrial septal defect. Because blood passes from the left atrium into the right atrium, blood flow increases across the pulmonic valve during systole, resulting in delayed pulmonic valve closure (wide splitting). The communication between the atria also causes equilibration of left atrial and right atrial pressures and eliminates respiratory variation in the splitting of S2 (fixed). splitting of S2 Educational objective: Patients with severe mitral regurgitation develop left ventricular volume overload and LV dilation, with an audible S3 gallop typically present. References: Valvular heart disease: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/20435842)

A 55-Year-Old Woman Comes to the Office Due to Persistent