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  #1  
Old 10-01-2012
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Arrow Billy Step 1 Questions #4

One week ago, a 72-year-old woman had an episode in which she became disoriented, had difficulty speaking, and
had weakness on the right side of the body. On physical examination, she is afebrile with pulse of 68/min, respirations of
15/min, and blood pressure of 130/85 mm Hg. On auscultation, the lungs are clear, the heart rate is irregular, and there is
a midsystolic click. An echocardiogram shows nodular deposits with the density of calcium around the mitral valve. One
leaflet of the mitral valve appears to balloon upward. The ejection fraction is estimated to be 55%. Laboratory findings
show Na+, 141 mmol/L; K+, 4.1 mmol/L; Cl−, 98 mmol/L; CO2, 25 mmol/L; glucose, 77 mg/dL; creatinine, 0.8 mg/dL;
calcium, 8.1 mg/dL; and phosphorus, 3.5 mg/dL. Which of the following is the most likely diagnosis?

(A) Carcinoid heart disease
(B) Hyperparathyroidism
(C) Infective endocarditis
(D) Infiltrative cardiomyopathy
(E) Mitral annular calcification
(F) Rheumatic heart disease
(G) Senile calcific stenosis
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  #2  
Old 10-01-2012
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i'll go with E) mitral annular calcification???
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  #3  
Old 10-02-2012
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Correct Answer E is correct

(E) Mitral annular calcification is often an incidental finding on chest radiograph, echocardiograph, or at autopsy.
Larger accumulations of calcium in the mitral ring can impinge on the conduction system, however, causing arrhythmias or
disrupting the endocardium to provide a focus for thrombus formation (which can embolize and cause a “stroke,” as in this
patient) or infective endocarditis. Some cases are associated with mitral valve prolapse. Carcinoid heart disease leads to
endocardial and valvular collagenous thickening. Hyperparathyroidism can cause metastatic calcification, which usually
does not involve the heart, and deposits would not be so focal; this patient does not have hypercalcemia. Infective
endocarditis is a destructive process, and healing may lead to fibrosis, but not to nodular calcium deposition. The most
common infiltrative cardiomyopathies are hemochromatosis and amyloidosis. Rheumatic heart disease can lead to scarring
with some calcium deposition, but the valve leaflets undergo extensive scarring, with shortening and thickening of the
chordae that preclude upward prolapse. Senile calcific stenosis involves the aortic valve; in this case, there is no evidence
of stenosis.
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  #4  
Old 10-02-2012
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Thanx for the cases Billy...they r very challenging n informative...
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