A 55-year-old man comes to the hospital because of progressively increasing shortness of breath for 1-hour ago. He has no chest pain. He has rheumatic heart disease and type 2 diabetes mellitus. He emigrated from India about 25 years ago. His current medications include carvedilol, torasemide, and insulin. He appears uncomfortable. His temperature is 37.3°C (99.1°F), pulse is 72/min and regular, respirations are 18/min, and blood pressure is 130/80 mm Hg. Physical examination reveals a diastolic murmur. Chest x-ray shows severe pulmonary vascular congestion and edema. However, during his hospitalization, he develops right-sided hemiparesis. Which of the following additional findings in this patient would be most suggestive of combined disease involving the mitral and aortic valves rather than exclusive mitral involvement?

Question

A 55-year-old man comes to the hospital because of progressively increasing shortness of breath for 1-hour ago. He has no chest pain. He has rheumatic heart disease and type 2 diabetes mellitus. He emigrated from India about 25 years ago. His current medications include carvedilol, torasemide, and insulin. He appears uncomfortable. His temperature is 37.3°C (99.1°F), pulse is 72/min and regular, respirations are 18/min, and blood pressure is 130/80 mm Hg. Physical examination reveals a diastolic murmur.  Chest x-ray shows severe pulmonary vascular congestion and edema.   However, during his hospitalization, he develops right-sided hemiparesis.  Which of the following additional findings in this patient would be most suggestive of combined disease involving the mitral and aortic valves rather than exclusive mitral involvement?

Quizplus · Accepted Answer

Eductional Objective: Isolated mitral stenosis causes elevated upstream pressures in the left atrium and pulmonary veins and arteries.  Left ventricular end diastolic pressure (LVEDP) is normal or decreased due to obstruction of blood flow through the stenotic valve.  An elevated LVEDP suggests additional downstream pathology (eg, aortic valve disease, left ventricular failure).

A 55-Year-Old Man Comes to the Hospital Because of Progressively