sob - woodywoodpecker

[ArchivalUser]

You are evaluating a 43-year-old woman who complains
of dyspnea on exertion. She was well until 2 months
ago when she noticed decreasing exercise tolerance and fatigue.
She denies chest pain but does have New York Heart
Association class II symptoms. She has no orthopnea or
paroxysmal nocturnal dyspnea. She has noticed bilateral
ankle swelling that improves with recumbency. She has one
child and has no other past medical history. On cardiac examination,
the jugular venous pressure is slightly elevated.
There is a prominent a wave. There is a right-ventricular
tap felt along the left sternal border. S1 is prominent and P2
is accentuated. There is a sharp opening sound heard best
during expiration just medial to the cardiac apex, which
occurs shortly after S2. A diastolic rumble is heard at the
apex with the patient in the left lateral decubitus position.
Hepatomegaly and ankle edema are present. The pulse is
regular and blood pressure is 108/60 mmHg. This patient
is at high risk for developing which of the following?
A. Atrial fibrillation
B. Left-ventricular dysfunction
C. Multifocal atrial tachycardia
D. Right bundle branch block
E. Right-ventricular outflow tract tachycardia

[ArchivalUser]

patient has MS..so high risk of developing AF

[ArchivalUser]

agreed, A fib

[ArchivalUser]

The answer is A.This patient has the opening snap, diastolic rumble, and
signs of pulmonary hypertension indicative of mitral stenosis (MS). The most common
cause is sequelae of rheumatic carditis, and symptoms of stenosis usually develop two
decades after the onset of carditis. MS can remain asymptomatic for many years but be
exaggerated when there is tachycardia, increased left-ventricular filling pressure, or reduced
cardiac output (e.g., fever, excitement, anemia, atrial fibrillation, pregnancy, or
thyrotoxicosis). Due to elevated left atrial pressure and concomitant left atrial dilation,
these patients are at high risk for developing atrial fibrillation, pulmonary hypertension,
and right-ventricular failure. Multifocal atrial tachycardia is commonly due to diseases
of the lung parenchyma. Right-ventricular outflow tract tachycardia is unrelated to valvular
pathology and is common in the young and women. Patients with MS do not develop
primary left-ventricular dysfunction because the left ventricle is protected from
the pressure and volume load by the diseased mitral valve. Patients with MS can develop
right-ventricular hypertrophy and right-ventricular failure. Right bundle branch block is
usually unrelated to MS.