Clinical MCQs

[Oak]

I love MCQs and infact I'm inspired by xenoMED team who are regularly bring out with the MCQs and the Soul's Clinical Questions and Answers initiations.

Therefore I will also post the question and answer on daily basis in this thread. Hope everyone of you will be benefited.

Here is my first MCQ on Rhematic Fever:



A 40-year-old woman has had several episodes of rheumatic fever as a child. She is currently afebrile and feels well, and has come to a hospital for monitoring echocardiography. Which of the following would be most likely to be seen in this patient's mitral valve?

A. Ballooning of valve leaflets
B. "Fish mouth" valve
C. Irregular beads of calcification in annulus
D. Large bulky vegetation with adjacent leaflet perforation
E. Tiny vegetations along line of closure of valve leaflet

[Arjun]

The answer is FISH MOUTH mitral valve.

But the problem here is that you will be able to see the FISH MOUTH valve only if you are lucky enough to dissect out that womens heart which she won't allow you in a million years

[Soul]

This woman has a history of rheumatic fever during her childhood. generally mitral valve is the first valve to be affected in RHD. Initially it presents with MR but gradually scarring of the valve causes MS. I guess the correct answer in this case should be- B "fish mouth" shape due to chronic rheumatic scarring.
Though 3D echocardiography can view 'fish mouth' appearance it's generally unavailable in many centres. Arjun is right. Then the answer is A-Billowing of valve leaflet during systole into left atrium-Mitral valve prolapse.. Therefore, physical examination is very important. Mid systolic click with late systolic murmur in MVP whereas Mid diastolic murmur with OS in MS will certainly help.
If 3D echo was not done then the answer is A. (i am not sure whether 2D echo can identify 'fish mouth' apperance of MV, though stenosis as small as 0.4 cm2 can be identified by 2D echo).
We may use the famous Sherlock Holmes technique: "It is an old maxim of mine that when you have excluded the impossibility, whatever remains, however improbable, must be the truth."
If the answer is B- then the mitral stenosis should be very severe and there should be signs and symptoms like dyspnea, chest discomfort etc etc... But this woman is not complaining of any.
Vegetations are usually in Infective endocarditis --as a complication of rheumatic heart disease. But fever is must in this case and there are no other s/s of IE.
So most likely Dx is "A". As a said before physicals are important. Listen heart murmur and make a Dx.

[Oak]

Great Guys, here is the explanation:

The correct answer is B. Acute rheumatic fever is a multisystem inflammatory disease that can follow group A streptococcal pharyngitis. The heart is a primary target of this disease and may be damaged sufficiently to develop permanent sequelae. The most important of these sequelae is chronic rheumatic heart disease with valvular damage. The damage most often involves the mitral and/or aortic valves.

The resulting thickened, blunted cardiac valve leaflets, often with fibrous bridging between valve leaflets and calcification, frequently take on a "fish mouth" or "button hole" stenotic morphology.

• choice A = ballooning of valve leaflets is seen in mitral valve prolapse.
  
• choice C = irregular, beadlike calcifications on the annulus is seen in calcification of the mitral annulus, seen in elderly individuals.
  
• choice D =large vegetations and leaflet perforation is seen in acute bacterial endocarditis, which usually involves healthy, rather than previously damaged, valves.
  
• choice E = Tiny vegetations along line of closure of valve leaflet is seen in marantic (nonbacterial thrombotic) endocarditis, most typically seen at autopsy of patients who die after protracted illness.

[nimsbdr]

fish mouth

[arunramani]

hi guys
good question