A case of severe mitral valve stenosis

Could a cardiac condition be causing a woman's fatigue, cough and hoarse voice?

A 34-year-old woman who moved from the NT to tropical Queensland in her early teens attends a GP.

heart

Over a period of six months, she has developed exertional dyspnoea, extreme fatigue, cough, wheeze and minimal haemoptysis.

She has also more recently noticed hoarseness in her voice.

Examination

The woman has pinkish-purple patches on her cheeks, which are consistent with a malar flush. Her central venous pressure is elevated to the angle of her jaw.

On auscultation, with the stethoscope bell applied to the apex of the heart in the

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