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2) A 23-year-old man with rheumatic mitral regurgitation presents to your clinic with frequent palpitations and exercise intolerance. He is currently in no distress and other wise appears healthy. He is a current smoker and has a 10 pack-year smoking history. He has no history of diabetes and has never been hospitalized since he had rheumatic fever as a child.

Which one of the following is not an indicator of the severity of his mitral regurgitation?

A) Third heart sound
B) The loudness of the murmur.
C) Signs of heart failure.
D) Presence of thrill.
E) S4

Explanation will be posted soon....
 

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s4 is equal to fat and hypertrophic heart ;
it means that heart encounters resistance of blood flow so it tries harder to overcome this resistance and in this course it becomes hypertrophic.
such resistance will be seen at ; AS,HOCM(hypertrophic obstructive cardiomyopathy),HTN
after appearing hypertrophy, heart hasn't capacity for accepting blood of atrial contraction(late diastole) and you will hear s4(atrial contraction)
in MR (mitral regurgitation) heart encounters a highway ;both aorta and mitral
so any resistance,any s4
 

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Mitral regurgitation leads to pulm edema, which can cause signs of heart failure(S3, JVD). Usually the louder the murmur, the higher the grade of MR, and the higher the severity on a grade of 1-6. A grade 4 MR will give you a loud murmur with a thrill. Actually the difference between a grade 3 and 4 is a thrill. A grade 3 has loud murmur but no thrill, while grade 4 has loud murmur and a thrill.

So the answer is S4, E
 
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