View source for WBR0842

{{WBRQuestion
|QuestionAuthor=Neeraja Danda M.B.B.S
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A 24 year old female in her 12th week of gestation came to the office complaining difficulty in swallowing. She has noticed a change in her voice as well. Auscultation at the apex reveals an opening snap followed by a diastolic murmur. Which one of the following is true regarding patient’s condition?
|Explanation=The murmur of mitral stenosis increases in intensity on squatting as the venous return increases and the blood flow through the valve increases. It also increases on leg rising for the same reason.  Mitral stenosis is most often caused by rheumatic fever.  Pregnancy can precipitate symptoms of mitral stenosis in otherwise asymptomatic patients.

'''Educational objective:''' The murmur of mitral stenosis increases on Squatting and leg rising. 

'''References:''' Page 59, 65 Master the boards Step 3 2009, Page 86, 87, 88 Master the boards step 2 CK second edition
|AnswerA=Transesophageal echocardiogram is the best initial test.
	

|AnswerAExp='''Incorrect''' Transesophageal echocardiogram is the most accurate but the best initial test is transthoracic echocardiogram        
	

|AnswerB=Valve replacement is must in all cases
|AnswerBExp='''Incorrect''' Valve replacement is not the choice of treatment in this case of mitral stenosis. The indication for invasive treatment with either a mitral valve replacement or valvuloplasty is NYHA functional class III or IV symptoms.
|AnswerC=Pregnancy is a contraindication to surgical intervention
|AnswerCExp='''Incorrect''' Pregnancy is not a contraindication for valvuloplasty.
|AnswerD=Hoarseness of voice is due to compression of superior laryngeal nerve
|AnswerDExp='''Incorrect''' Hoarseness of voice is due to compression of recurrent laryngeal nerve by the enlarged left atrium.
|AnswerE=Murmur increases in intensity on squatting
|AnswerEExp=The murmur of mitral stenosis does increase on Squatting and leg rising. 
|RightAnswer=E
|WBRKeyword=mitral stenosis
|Approved=Yes
}}