A 70 years old woman presents to ur office with a chief complaint of fatigue and dyspnea on exertion. she denies chest pain, cough, light-headedness, syncope or orthopnea. she takes no medications. on examination, BP is 128/76, respiratory rate 12. JVP is flat, and lung are clear. cardiac murmur shows a normal S1, S2 with a 3/6 holosystolic murmur at the left sternal border that radiates to the axilla. there are normal pulses and no edema...

ECG show left atrial enlargment, no ventricular hypertrophy, and no evidence of ischemia or prior MI...

- the most likely cause of this patient heart condition is?
a- syphilis.
b- rheumatic heart disese.
c- endocarditis.
d-myxomatous degeneration of the valve.
e-rupture of papillary muscle.


- the most appropriate treatment at this time would be to start?
a- furosemide.
b- captopril.
c- digoxin
d- antibiotics.
e- warfarin....

ENJOY...

i would choose b and d

ali

Hi..i think :


d-myxomatous degeneration of the valve



e- warfarin


thx Ahmad for your nice cases

hi ahmed,

this patient probably has degenerative mitral regurgitation.
it would be cool if she has a history of MI to suggest papillary rupture but she doesnt.
endocarditis and rheumatic fever would probably cause stenosis and regurg more than regurg at the same time.
syphilis usually causes aortic root and aortic valve disease.

treatment i should be directed to reduce the afterload so that the cardiac output improves and the regurgitant flow will decrease. so Captopril is the choice in think.

digoxin is not idicated unless she is in refractory heart failure or she has atrial fibrillation with a rapid response.

diuretics will reduce the preload but may have deletrious effects on the cardiac output.

warfarin is not indicated, because with regurgitation we will have a hyperdynamic blood flow in the left atrium so there is actually less risk of thrombus formation even in with the presence of Atrial fibrillation.

there is such case and almost the same hx in the ninth floor i saw her on monday 18 feb. ( female i think her name was Zainab (?))

as the perminant resident said, she has mitral regurgitation, probably due to rheumatic heart disese, But she said that she did not have any medical problem before this time.....
and she's now 45 yrs old..


Wish to be contin..d