A 50-year-old white man comes to the emergency department after a syncopal episode that occurred at

Discussion in 'Step 3' started by samuel, Dec 13, 2014.

  1. samuel

    samuel New Member

    A 50-year-old white man comes to the emergency department after a syncopal episode that occurred at home while carrying heavy groceries from his car. He has no significant past medical history but has not been to a doctor in “many” years. Further history reveals that he has been having substernal chest pain and shortness of breath with exertion over the previous 5 weeks. His temperature is 37.0 C (98.6 F), blood pressure is 170/60 mm Hg, pulse is 93/min, and respirations are 16/min. Physical examination reveals a well developed man in no acute distress. He has 12 cm of jugular venous distension. His carotid upstroke is slowed. His lungs have bibasilar crackles. His heart rate is regular with a long, late-peaking, systolic murmur heard at the right upper sternal border. His S2 is paradoxically split. An S4 is appreciated. His murmur is louder while lying down. He has 1+ bilateral lower extremity edema. A transthoracic echocardiogram confirms your diagnosis. When questioned, he denies a history of rheumatic fever. Which of the following is the most likely diagnosis?
    A. Aortic stenosis secondary to a calcified bicuspid aortic valve
    B. Aortic stenosis secondary to a calcified tricuspid aortic valve
    C. Idiopathic hypertrophic subaortic stenosis
    D. Severe mitral regurgitation
    E. Ventricular septal defect

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