[Seetal]

A 28-year-old man who had rheumatic fever as a child comes to the physician's office because of fatigue and dyspnea for the past 4 months. An early diastolic sound followed by a low-pitched rumbling decrescendo diastolic murmur is present 4 cm left of the sternal border in the fourth intercostal space and is heard best with the patient in the left lateral decubitus position. Which of the following valve defects is most likely in this patient?

(A) Aortic regurgitation
(B) Aortic stenosis
(C) Mitral regurgitation
(D) Mitral stenosis
(E) Pulmonic regurgitation
(F) Pulmonic stenosis
(G) Tricuspid regurgitation
(H) Tricuspid stenosis

 

[HouseWannabe]

A?

I don't have a full explanation and i really wanna say it's a mitral prob because of the rheumatic fever but my mind keep pulling me towards Aortic Regurg. A.

I mean technically RF causes both Aortic and mitral prob, and no matter how i look at it mitral would make it a late diastolic prob and this question says early...

I completely confused myself trying to explain Aortic regurg to myself.

 

[sam01]

i was confused but now i see.The early diastolic rumbling is Austin Flint murmur seen in aortic regurgitation.it may mimic mitral stenosis but it s because regurgitant stream from incompetent aortic valve hits the anterior mitral leaflet

 

[Seetal]

sorry guys. the correct answer is D. mitral stenosis.

dr.house, again u should follow that voice within.

i actually posted this question because i had made my own mnemonic while i was studying physiology and well i got pretty excited when i came across this question. and i wanted to share my mnemonic!

AIDS is an ASS
(Aortic Insufficiency = DiaStolic murmur) = Mitral Stenosis
(Aortic Stenosis = Systolic murmur) = Mitral Insufficiency

and do the opposite for mitral stenosis & mitral insufficiency. in RHD, the valve MOST commonly involved is mitral and it causes INSUFFICIENCY, so systolic murmur. but in this CASE they mention mitral stenosis, which can happen, so it is Diastolic murmur)

also, if u read the case again, the sound is at 4cm LEFT to the sternal border at the 4TH ICS (almost reaching the where the apex sound will be most heard). at the 4th ICS we only here tricuspid and mitral sounds (not aortic or pulmonary, which are at the 2nd ICS)

i hope that was helpful.

 

[HouseWannabe]

I think what confused me is that the question stated early diastolic murmur, and i know Mitral stenosis is Late diastolic, so it kept throwing me off.

 

[sam01]

tough question.i thought it was an aortic regurgitation with functional mitral stenosis.But i m still confused cause Austin Flint murmur is also heard in the apical area and they put the decrescendo thing.That s why i chose A.Are u sure it s D?

 

[HouseWannabe]

tough question.i thought it was an aortic regurgitation with functional mitral stenosis.But i m still confused cause Austin Flint murmur is also heard in the apical area and they put the decrescendo thing.That s why i chose A.Are u sure it s D?

I think with Aortic regurgitation it would be right to the sternal border of the location specified, where as in this case, the murmur heard was left of the border.

 

[Seetal]

tough question.i thought it was an aortic regurgitation with functional mitral stenosis.But i m still confused cause Austin Flint murmur is also heard in the apical area and they put the decrescendo thing.That s why i chose A.Are u sure it s D?

haha.. yes dr. Sam. im VERY sure the answer is D. this is my fav type of question (the heart sounds)

 

[memo.3tef]

mitral stenosis

early diastolic may be AR
but murmer increase with Lt lateral position
confirm M.S

 

[ecgram]

yup its MS

u can also remember them in this way

u can divide into 2 groups semilunar , AV valves

just remmeber AS is systolic then everything u can think logically , the other group is undergoing regurgitation =MR (systolic)

so the remaining 2 types will be diastolic MS and AR


i dont no if this make sense but thats how i rememebered

 

[hana]

past history of this patient is very helpful and makes the q easssssssssy;

1-chronic RHEUMATIC FEVER CAUSE MS(mcc of MS) OR AS.
2-MURMUR IS DURING DYATOL .....MS.


about murmurs ALL are SYSTOLIC except ARMS (AR, MS)