Mitral stenosis physical examination


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Overview
Mitral stenosis is associated with a rumbling diastolic murmur and an opening snap. Later in the course of the disease there are signs of right heart failure such as pedal edema, ascites, and congestive hepatopathy.

Vitals

 * Tachycardia may be present if there is a reduction in cardiac output
 * The pulse may be irregularly irregular with the onset of atrial fibrillation

Head
There is sometimes a mitral facies with patches of pink and purple on the face due to peripheral vasoconstriction. There may be a malar flush.

Neck

 * Jugular venous distension
 * V waves with tricuspid regurgitation
 * There is a loss of the a wave with the onset of atrial fibrillation

Palpation

 * Left parasternal heave is palpable if right ventricular hypertrophy is present due to pulmonary hypertension
 * Due to the underfilling of the left ventricle, the PMI may not be palpable or displaced
 * A diastolic thrill may be palpated rarely
 * A P2 may be palpable in the 2cd left intercostal space
 * A right ventricular lift may be present

The Opening Snap of Mitral Stenosis
The closing of the mitral valve and the tricuspid valve constitutes the first heart sound (S1). It is not actually the valve closure which produces a sound but rather the sudden cessation of blood flow caused by the closure of the mitral and tricuspid valves. The mitral valve opening is normally not heard except in mitral stenosis as the opening snap. As the severity of the mitral stenosis increases, the pressure in the left atrium increases, and the mitral valve opens earlier and more abruptly in ventricular diastole. An opening snap which is a high pitched additional sound may be heard after the A2 (aortic) component of the second heart sound (S2), which correlates to the forceful opening of the mitral valve. Initially, an opening snap is heard because there is an increased gradient between the left atrium and the left ventricle and S1 is loud. As the valve calcifies and left atrial pressure increases, S1 becomes softer and the opening snap moves closer to S2.

Mid-diastolic rumbling murmur heard after the opening snap
The murmur is best heard at the apical region and is not radiated. Since it is low-pitched it should be picked up by the bell of the stethoscope. Rolling the patient towards left, as well as isometric exercise will accentuate the murmur. If the patient is in normal sinus rhythm, there will be a “presystolic accentuation” of the murmur due to increased flow across the valve with normal atrial contraction. The duration of the murmur and not the intensity of the murmur correlates with the severity of mitral stenosis.

 An opening snap
 * S1:The first heart sound is unusually loud and may be palpable due to the increased force of the closing of the mitral valve.
 * S2:If pulmonary hypertension secondary to mitral stenosis is severe, the P2 (pulmonic component of the second heart sound (S2) will become loud. When pulmonary hypertension develops, murmurs of pulmonary insufficiency (Graham Steel murmur), tricuspid regurgitation and a right sided S3 can be heard.
 * S3: Flow of blood into the heart during rapid filling is not normally heard except in certain pathological states where it constitutes the third heart sound (S3).

Periphery

 * Ankle/sacral edema when there is right heart failure