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Old 10-19-2011
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Default Cardiology

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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Old 10-19-2011
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A. Aortic stenosis secondary to a calcified bicuspid aortic valve
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A.AS secondary to calcified bicuspid aortic valve
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A. Aortic stenosis secondary to a calcified bicuspid aortic valve
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Default Answer

The correct answer is A. This patient has aortic stenosis (AS). He has the classic triad of syncope, chest pain, and signs of left ventricular failure. His physical examination is consistent with this diagnosis. He has a systolic murmur at the right upper sternal border. He has a paradoxically split S2 from the calcifications of this valve. An S4 is heard that is caused by the atrium contracting into a stiff ventricle. His carotid upstroke is slowed. Finally, his lung examination is consistent with left ventricular failure. A bicuspid valve is a fairly common inherited valve disorder. Patients with AS secondary to bicuspid valves tend to develop symptoms between 40 and 70 years of age. Patients with tricuspid aortic valve stenosis (choice B) tend to develop symptoms after they are approximately 80 years of age. However, children may develop symptomatic aortic stenosis following rheumatic fever. Patients with symptomatic aortic valve disease need to have their heart valves replaced surgically.

The murmur of idiopathic hypertrophic subaortic stenosis (choice C) is a harsh midsystolic murmur. It often is accompanied by an S4. Carotid upstroke is brisk (unlike this patient) and bifid. Standing and Valsalva maneuver increase the murmur.

Mitral regurgitation (MR) (choice D) also causes a systolic murmur, but it has different characteristics than the murmur of AS. A chronic MR murmur is a pansystolic murmur. It is louder in expiration. The S2 is widely split because of early closure of the aortic valve.

The murmur of a ventricular septal defect (VSD) (choice E) is holosystolic and heard best at the left lower sternal border. It may be heard after an MI with a ventricular septal rupture.
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