Malar flush – Patients with severe MS, low cardiac output, and systemic vasoconstriction may develop pinkish-purple patches on checks called a malar flush.

Pulse: pulse is usually normal, maybe small in volume due to reduced stroke volume.

Rhythm may be irregular – irregular due to atrial fibrillation).

Inspection

Left parasternal pulsation is seen due to right ventricular hypertrophy or forward displacement of the heart by a dilated left atrium.

Palpation

Apex beat is not displaced.

Tapping apex beat

Left parasternal heave may be felt due to right ventricular hypertrophy secondary to mitral stenosis

Palpable P2 in case of pulmonary hypertension.

Diastolic thrill at the apex (in left lateral position)

Auscultation

Loud first heart sound

Loud P2

Opening snap

Mid-diastolic rumbling murmur (Best heard with the bell of the stethoscope with the patient in left lateral position). The length of the murmur is proportional to the severity of mitral stenosis. The murmur may become loud if the patient exercises prior to auscultation.

Pre-systolic accentuation of murmur

Investigation

ECG • Bifid P wave (wide and notched P wave) called P-mitral in lead II indicates left atrial enlargement. • Right ventricular hypertrophy – (Right axis deviation and tall R wave in lead VI and deep S wave in lead V6) may be present. • Atrial fibrillation may be present.

CXR – This shows (Mitralization) • Small heart with an enlarged left atrium which may be visible as a double shadow behind the right border of the heart. Straightening of the left border of the heart

Echocardiogram