HISTORY. Question the patient about a history of rheumatic fever because 50% of all cases of chronic mitral insufficiency are attributed to rheumatic heart disease. Because mitral valve prolapse, a common form of mitral insufficiency, has a familial association, determine if others in the family have the condition. Coronary heart disease contributes to both chronic and acute disorders; therefore, ask the patient if she or he has chest pain or palpitations. Determine if the patient has the classic symptoms of fatigue and shortness of breath. Other symptoms include orthopnea, palpitations, irregular heartbeat, exertional dyspnea, edema, and weight loss.

PHYSICAL EXAMINATION. Inspection and palpation of the precordium are usually unremarkable except in extreme cases of mitral insufficiency. Auscultation of the chest usually reveals a soft first heart sound and a systolic murmur, which is loudest at the apex. In severe mitral insufficiency, you may hear an S3 gallop. Auscultation of breathing may reveal fine crackles (rales) if pulmonary congestion is present. When the abdomen is palpated, you may note an

614 Mitral Insufficiency (Regurgitation)

enlarged liver if the patient has severe right-sided heart failure. The patient may also have jugular vein distension and a prominent alpha wave.

PSYCHOSOCIAL. In an effort to avoid exertional dyspnea and fatigue, patients usually adjust their lifestyles by restricting their activity and resting frequently. They may not notice the increasing fatigue until it gets debilitating. Assess the patient's level of exercise and how he or she copes with activity intolerance.

Diagnostic Highlights


Normal Result

Abnormality with Condition



Normal mitral

Incompetent mitral valve

Mitral valve is incompetent and



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