A 40-year-old man with a history of rheumatic fever in childhood is most likely to have which murmur now?

• A. Aortic regurgitation
• B. Mitral regurgitation
• C. Mitral stenosis
• D. Tricuspid stenosis

Answer: (C)

Rheumatic fever classically leaves the mitral valve damaged, and over years this damage tends to cause mitral stenosis, the most common late valvular consequence. In middle age, a diastolic murmur best heard at the apex in the left lateral position with an opening snap reflects the stiff, narrowed mitral valve. The stiff leaflets impede flow from left atrium to ventricle, raising left atrial pressure and causing dyspnea and potential pulmonary congestion. While other valvular lesions can occur with rheumatic disease, the combination of a history of rheumatic fever and the typical diastolic apical murmur points most strongly to mitral stenosis.