WBR278

Author	[[PageAuthor::Sapan Patel M.B.B.S]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Community Medical Health Center, MainCategory::Primary Care Office
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 68-year-old male is seen in the office for recurrent chest pain. He reports that he is getting substernal chest pain, without radiation, when he goes for a walk. The pain resolves with 12–15 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 130/68, pulse 86, and respiratory rate 14. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be the most appropriate test to order?]]
Answer A	AnswerA::Cardiac catheterization
Answer A Explanation	[[AnswerAExp::Incorrect- If aortic stenosis is found on echocardiogram and the patient is symptomatic, the next test would be cardiac catheterization. This would allow for direct measurement of the pressure gradient across the valve. It would also allow for evaluation of the status of the coronary arteries in order to determine whether CABG would need to be performed along with valve replacement.]]
Answer B	AnswerB::Electrophysiologic studies
Answer B Explanation	AnswerBExp::Incorrect- Electrophysiologic studies would not play a role in the typical evaluation of aortic stenosis.
Answer C	AnswerC::Exercise stress test
Answer C Explanation	AnswerCExp::Incorrect- Exercise stress testing is relatively contraindicated in the setting of symptomatic aortic stenosis.
Answer D	AnswerD::Echocardiogram
Answer D Explanation	AnswerDExp::Correct- see explantion.
Answer E	AnswerE::24-hour Holter monitor
Answer E Explanation	AnswerEExp::Incorrect- Holter monitoring would only be useful if there were a concomitant arrhythmia.
Right Answer	RightAnswer::D
Explanation	[[Explanation::EXPLANATION: Aortic stenosis is one of the most common valvular abnormalities found in adults. It can be congenital—such as a unicuspid or bicuspid valve—or acquired. In young adults, acquired aortic stenosis is often seen as a consequence of rheumatic fever. This is becoming less common in developed nations. In adults over the age of 65, the most common cause of aortic stenosis is age-related degenerative, calcific aortic stenosis. The valvular cusps are immobilized and the stenosis caused by calcium deposits along the flexion lines of the valves. Acquired aortic stenosis typically has a prolonged asymptomatic period. During this time the stenosis may be found incidentally by auscultation of the characteristic harsh, holosystolic murmur in the aortic valve area that radiates to the carotid arteries. There may also be a slow, small, and sustained arterial pulsation (pulsus parvus and tardus) due to the relative outflow obstruction. When considering the diagnosis of aortic stenosis, the initial diagnostic test of choice would be echocardiography. It would provide information on both the structure (bicuspid, tricuspid, and the like) and the function (valve area, pressures) of the valve. The size and function of the left ventricle can also be determined. EDUCATIONAL OBJECTIVE: Aortic stenosis is one of the most common valvular abnormalities found in adults. The initial diagnostic test of choice would be echocardiography. Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Aortic stenosis
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