Mitral valve disease is suggested by an episode of rheumatic fever during childhood with a murmur noted since then, and her history of palpitations that may be due to an associated atrial arrhythmia.

The patient’s history also provides clues to the severity and natural history of the specific lesion. Left heart failure typically presents with dyspnea on exertion, and her progressive fatigue and dyspnea are consistent with low cardiac output. Paroxysmal nocturnal dyspnea indicates some degree of pulmonary venocapillary hypertension and suggests that the lesion is severe. The presence of a murmur in a patient who is asymptomatic over many years, suggests a lesion associated with left ventricular volume overload, as volume overloads are well tolerated for decades.