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  #1  
Old 04-06-2011
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Arrow High Yield Question #10

Pt presents with exertional dyspnea with minimal activity. Past medical history is significant for acute rheumatic fever. Pressure 126/76 mmHg, PR 78, temp 37C. Auscultation of his lungs shows crepitations in both lower lung fields. Auscultation of heart reveals a loud first heart sound, mid systolic rumbling and a low pitched murmur at the apex. The murmur is accentuated by mild exercise. Which of the following findings is a hallmark of the suspected disease.

A) Left atrial enlargement
B) Wide pulse pressure
C) Atrial fibrillation
D) Elevated left atrioventricular pressure gradient
E) Elevated left ventricular diastolic pressure
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Old 04-06-2011
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Mitral stenosis is most common finding:
MS (a loud first heart sound) -> LA enlargement -> AF
A) Left atrial enlargement
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Old 04-06-2011
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Default A

I was debating between MS and MR, but since the murmur is not pansystolic, I am leaning toward MS. So I will go with A) LA enlargement
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Old 04-06-2011
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Default C?

I agree that it's probably mitral stenosis, but I was thinking C. atrial fibrillation.
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Old 04-06-2011
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Arrow D) Elevated left atrioventricular pressure gradient

I know it's bit tough one. This is most tested topic in USMLE exam. Make sure you know the mechanism of cardiac blood flow, pressure different and the pathological changes in the myocardium.

Correct ans is D) Elevated left atrioventricular pressure gradient

This is a case of MS. The qn is asking particularly the hallmark finding of MS. The hallmark finding of MS is elevated left atrioventricular pressure gradient that ultimately leads to left atrial enlargement (bebix and apx85 mentioned above). The elevated left atrial pressures are transmitted to the pulmonary veins, capillaries and arteries. These phenomena are responsible for the exertional dyspnea and later, pulmonary hypertension and right heart failure. Enlargement of the left atrium predisposes of atrial fibrillation (Mondoshawan mentioned above) which is quite common in mitral stenosis but is not the hallmark finding.

The left ventricular diastolic pressure is normal in mitral stenosis. These pressures become elevated when there is coexistent mitral regurgitation, aortic valve disease, systemic hypertension or coronary artery disease.

A wide pulse pressure is not a feature of mitral stenosis. It occur in aortic insufficiency.
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Old 04-06-2011
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The left ventricular diastolic pressure is normal in mitral stenosis. These pressures become elevated when there is coexistent mitral regurgitation, aortic valve disease, systemic hypertension or coronary artery disease.

Could you please explain how LV Diastolic pressure is elevated in Mitral regurgitation? I can understand why would it with other cases but not with MR.
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Old 04-07-2011
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i am confused as to why in the question, mid systolic murmur given as a finding? Is not a mid- diastolic murmur the hallmark of mitral stenosis?
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Quote:
Originally Posted by donofitaly View Post
The left ventricular diastolic pressure is normal in mitral stenosis. These pressures become elevated when there is coexistent mitral regurgitation, aortic valve disease, systemic hypertension or coronary artery disease.

Could you please explain how LV Diastolic pressure is elevated in Mitral regurgitation? I can understand why would it with other cases but not with MR.
I think that is because during regurgitation blood is regurgitated back to atrium and excess amount of blood..(normal venous return + regurgitated blood ) is pumped into the ventricles during diastole......thus elevating pressures....
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i am confused as to why in the question, mid systolic murmur given as a finding? Is not a mid- diastolic murmur the hallmark of mitral stenosis?

Same ques.??
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  #10  
Old 04-07-2011
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Arrow

Quote:
Originally Posted by sandy_presto3 View Post
i am confused as to why in the question, mid systolic murmur given as a finding? Is not a mid- diastolic murmur the hallmark of mitral stenosis?

Same ques.??
yes you are right. But Low frequency rumbling mid-diastolic murmur, with presystolic component possible. This is heard best at apex and accentuated in left lateral decubitus position. Clues: Loud S1 and low pitched murmur at the apex typical for MS.
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