WBR0650

Author	PageAuthor::Neeraja Danda M.B.B.S
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 27 year old female pregnant patient in her 26th week of gestation presents to the physician with complaints of difficulty in breathing, difficulty in swallowing and cough . Vitals include pulse rate 95/min, blood pressure 100/70 mm Hg and respiratory rate 22/min. On cardiac auscultation, a diastolic murmur after an opening snap is heard. Past history is significant for a fever which was treated with penicillin but she does not remember the diagnosis. She is an immigrant from India, having immigrated to the United States 5 years ago.What is the most likely diagnosis?]]
Answer A	AnswerA::Rheumatoid arthritis
Answer A Explanation	[[AnswerAExp::Incorrect Rheumatoid arthritis is a connective tissue disease characterized by pain and stiffness in the joints. Valvular disease can be a feature of rheumatoid arthritis. In a patient with a history of immigration and fever treated with penicillin, rheumatic fever is more likely. There are no other clinical signs of rheumatoid arthritis in this patient.]]
Answer B	AnswerB::Mitral regurgitation
Answer B Explanation	AnswerBExp::'''Incorrect''' Mitral regurgitation is characterized by a holosystolic murmur at the cardiac apex. Dyspnea on exertion is the most common presentation
Answer C	AnswerC::Mitral Stenosis
Answer C Explanation	AnswerCExp::Diastolic murmur after an opening snap is the classic presentation of mitral stenosis
Answer D	AnswerD::Endocarditis
Answer D Explanation	[[AnswerDExp::Incorrect Endocarditis is often accompanied by fever , and presents as a new murmur or change in an existing murmur. It is diagnosed by blood cultures and vegetations on cardiac valves on echocardiography. The patient in this vignette does not display fever or other acute infective symptoms]]
Answer E	AnswerE::Ventricular septal defect
Answer E Explanation	AnswerEExp::'''Incorrect''' Ventricular septal defects are characterized by a holosystolic murmur at the lower left sternal border
Right Answer	RightAnswer::C
Explanation	[[Explanation::The murmur described here is the classic murmur of mitral stenosis, a diastolic murmur after an opening snap. An immigrant patient with a fever treated with penicillin should raise suspicion for rheumatic fever. During pregnancy, plasma volume increases, thereby increasing blood flow through the narrowed mitral valve and causing pregnancy related cardiomyopathy. Other special features of mitral stenosis are due to pressure of enlarged left atrium on adjacent tracts. For example,dysphagia may occur due to pressure on esophagus, hoarseness of voice occurs due to pressure on recurrent laryngeal nerve and cough occurs due to pressure on the bronchus. Transthoracic echocardiogram is the best initial diagnostic test for all valvular diseases.Diuretics are the best initial therapy for mitral stenosis. Educational Objective: An immigrant pregnant patient with a diastolic murmur after an opening snap is the classic presentation of mitral stenosis due to rheumatic fever References: Page 29,30,86,87 Master the boards Step 2 CK second edition, Page 65,119 Master the boards step 3 2009 edition, http://www.wikidoc.org/index.php/Mitral_stenosis_history_and_symptoms C. Michael Gibson, M.S., M.D Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Mitral stenosis, WBRKeyword::Rheumatic fever, WBRKeyword::Opening snap
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