A 65-year-old woman undergoing maintenance haemo-dialysis for end-stage diabetic nephropathy was admitted because of worsening dyspnoea over 2 months despite intensive haemodialysis. Initial physical examination disclosed irregular heart beat, an accentuated P2 (pulmonic) component of the second heart sound with an opening snap. Cardiac auscultation also revealed a grade IV/VI low-pitched diastolic rumbling murmur and a grade V/VI pansystolic murmur at the apex.
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