Chief Complaint: 74-year-old woman withshortness of breath and swelling.
History: Martha Wilmington, a 74-year-old womanwith a history of rheumatic fever while in her twenties, presentedto her physician with complaints of increasing shortness of breath(\"dyspnea\") upon exertion. She also noted that the typical swellingshe's had in her ankles for years has started to get worse over thepast two months, making it especially difficult to get her shoes ontoward the end of the day. In the past week, she's had a decreasedappetite, some nausea and vomiting, and tenderness in the rightupper quadrant of the abdomen.
On physical examination, Martha's jugular veins were noticeablydistended. Auscultation of the heart revealed a low-pitched,rumbling systolic murmur, heard best over the left upper sternalborder. In addition, she had an extra, \"S3\" heartsound.
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Questions:
1. What is causing this murmur?
2. What is causing her \"S3\" heart sound?
3. Is her history of rheumatic fever relevant to her currentsymptoms? Explain.
4. A chest X-ray reveals a cardiac silhouette that is normal indiameter. Does this rule out a possible problem with Martha'sheart? Explain.
