Senior, Caucasian, 77-year-old, retired man. He was known to be a carrier of longstanding mitral-aortic rheumatic valvular heart disease.
He complained of dyspnea on moderate effort (NYHAII) since several months ago.
A week ago he had one syncopal episode, not associated with exercise that repeated at rest yesterday. He denied having angina pectoris precipitated by exertion or at rest.
Inspection: Jugular Venous Pulse (JVP) assessed with the patient reclined at a 45° angle, 3.5 centimeters above the sternal angle (normal <4 cm).
Palpation: Point of maximum impulse is better felt 1 cm at the left of the mid-clavicular line, roughly at the 6th intercostal space with increased vigor. Absence of thrills. BP 135/85 bpm. HR 60 bpm and regular. Auscultation: In mitral area, S1 with decreased intensity; a soft, low-pitched sound occurring after the second heart sound and preceding the murmur (diastolic opening snap), then diamond shaped low-pitched murmur and S3 gallop. Rectangular mid-frequency systolic murmur.
Over the 2nd right intercostal space (aortic area), systolic click followed by crescendo-decrescendo murmur (diamond shaped murmur), ending just before the second heart sound with radiation into the right neck. The S2 is diminished in intensity (A2).
A diastolic high-pitched, musical decrescendo murmur is better heard in the third left intercostal space and irradiates widely along the left sternal border.