A 55-year-old woman comes to the physician for a routine preventive examination. Her only symptoms are minor aches and pains in various muscles. She has been diagnosed with irritable bowel syndrome, fibromyalgia, depression, and rheumatic heart disease. Current medications include fluoxetine and ibuprofen. Temperature is 37.0 C (98.6 F), blood pressure is 128/86 mm Hg, pulse is 80/min, and respirations are 14/min. Heart auscultation shows a low-pitched, rumbling diastolic murmur preceded by an opening snap. The affected cardiac valve is best auscultated at which of the following regions?
A)Between the fifth and sixth ribs at the left mid-clavicular line
B)Between the fifth and sixth ribs at the left sternal border
C)Between the fifth and sixth ribs at the right sternal border
D)Between the second and third ribs at the left sternal border
E)Between the second and third ribs at the right sternal border

Question

A 55-year-old woman comes to the physician for a routine preventive examination.  Her only symptoms are minor aches and pains in various muscles.  She has been diagnosed with irritable bowel syndrome, fibromyalgia, depression, and rheumatic heart disease.  Current medications include fluoxetine and ibuprofen.  Temperature is 37.0 C (98.6 F), blood pressure is 128/86 mm Hg, pulse is 80/min, and respirations are 14/min.  Heart auscultation shows a low-pitched, rumbling diastolic murmur preceded by an opening snap.  The affected cardiac valve is best auscultated at which of the following regions?
A)Between the fifth and sixth ribs at the left mid-clavicular line
B)Between the fifth and sixth ribs at the left sternal border
C)Between the fifth and sixth ribs at the right sternal border
D)Between the second and third ribs at the left sternal border
E)Between the second and third ribs at the right sternal border

Quizplus · Accepted Answer

Explanation: 11ec2b69_c11b_d5db_8f63_63cde2254061_MD0005_00 Mitral stenosis (MS) arises from a thickening of the mitral valve leaflets that obstructs blood flow from the left atrium to the left ventricle. This obstruction results in increased pressure within the left atrium, the pulmonary vasculature, and the right ventricle and atrium. The most common cause of MS is rheumatic fever, as in this patient; involvement of the mitral valve is thought to occur in up to 90% of individuals with rheumatic heart disease. Mitral stenosis (MS) The murmur of mitral stenosis is a soft, low-pitched rumble best heard with the bell of the stethoscope at the cardiac apex, which is located in the fifth intercostal space (between the 5th and 6th ribs) at the left mid-clavicular line. It is often helpful if the patient exhales and lies in the left lateral decubitus position. (Choice B) The tricuspid valve is best auscultated at the fifth intercostal space at the left sternal border. (Choice C) No valve is best auscultated at the fifth intercostal space at the right sternal border. (Choice D) The pulmonic valve is best auscultated at the second intercostal space at the left sternal border. (Choice E) The aortic valve is best auscultated at the second intercostal space at the right sternal border. Educational objective: Mitral stenosis is best heard with the bell of the stethoscope at the cardiac apex, which is located in the fifth intercostal space at the left mid-clavicular line. It may be helpful if the patient lies in the left lateral decubitus position.

A 55-Year-Old Woman Comes to the Physician for a Routine