D. Mitral regurgitation – Explanation

The patient has mitral regurgitation secondary to rheumatic fever.

Some exam clinchers for mitral regurgitation:

• Previous disease that affects the mitral valve
• Signs and symptoms of pulmonary oedema will appear in the stem
• Panysystolic murmur at the cardiac apex is the murmur of mitral regurgitation
• Chest X-ray if given may show an enlarged left side of the heart

MITRAL REGURGITATION
Common scenarios in the exam are:

• History of rheumatic fever
• A few weeks after a myocardial infarction where patient may be admitted for pulmonary oedema

Clinical features
Left ventricular failure

• Dyspnoea
• Orthopnoea
• Paroxysmal nocturnal dyspnoea

With severe and chronic mitral regurgitation, right-sided failure would eventually occur leading to:

• Oedema
• Ascites

Important clinical sign – Pansystolic apical murmur radiating to the axilla
ECG – signs of left ventricular hypertrophy and left atrial enlargement (e.g. broad P wave)
Chest X-ray – may show an enlarged left side of the heart

Diagnosis
Echocardiography

The table is for reference. Only common murmurs are usually asked in the exam

Defect	Type of Murmur	Where Is It Heard?	Symptoms
Aortic Stenosis	Ejection Systolic	2nd intercostal space to the right of the sternum	Dyspnoea with activity, anginal chest pain, and syncope
Aortic Regurgitation	Early Diastolic	N/A	Symptoms of heart failure
Mitral Stenosis	Mid-late Diastolic	Apex	Symptoms of heart failure
Mitral Regurgitation	Pan-Systolic	Apex	Symptoms of congestive heart failure
Pulmonary Stenosis	Ejection Systolic	2nd intercostal space to the left of the sternum	Systemic cyanosis
Pulmonary Regurgitation	Early Diastolic	N/A	Symptoms of right-sided heart failure
Tricuspid Stenosis	Diastolic Rumble	Lower right sternal edge	Fluttering discomfort in the neck
Tricuspid Regurgitation	Pan-Systolic	Lower right sternal edge	Symptoms of right-sided heart failure