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Old 10-19-2011
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Default Cardiology

A 30-year-old man comes to the office for an annual physical examination. He is otherwise healthy with no complaints of chest pain, lightheadedness, or dizziness. He takes no medications. His pulse is 70/min and blood pressure is 145/87 mm Hg. Carotid upstrokes are brisk. On cardiac examination he has a grade 3/6 diastolic murmur that is loudest at the left sternal border and best heard when the patient is sitting up and leaning forward. Which of the following is the most appropriate management at this time?
A. Initiate metoprolol 25 mg twice a day
B. Initiate lisinopril 10 mg once a day
C. Observe the patient until symptoms develop
D. Obtain an echocardiogram
E. Schedule cardiac catheterization
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Old 10-19-2011
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D. Obtain an echocardiogram?
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Old 10-19-2011
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I have to say that pass7 and me have the same exact answers for the last 7 questions i read. I hope it a great minds think alike and its the correct answer kind of thing and not a we are making a common mistake thing.
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Old 10-20-2011
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i think its AR so obtain echo first..
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D...obtain an echo???
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C. Observe the patient until symptoms develop
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  #7  
Old 10-20-2011
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he does have high BP, i think he should be treated! his diastolic is not too low so perfusion would not be an issue with some moderate lowering of BP. i'd go with lisinopril?
But i think he should get an echo since it could be a manifestation of anything not yet symptomatic. dissection for instance. so next best : echo
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Old 10-20-2011
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Correct Answer Answer

The correct answer is D. This patient has aortic insufficiency. Given his age, the most likely reason for the murmur is a congenital bicuspid aortic valve. Typically, the diagnosis is made when the patient is young and has regurgitation or after aortic stenosis develops. The patient must undergo an echocardiogram for diagnosis.

Metoprolol (choice A) would worsen the patientís regurgitation by prolonging diastole.

Lisinopril (choice B) would be useful if the patient had left ventricular dilation, by providing afterload reduction.

Observation (choice C) could prove fatal in the long term if irreversible left ventricular damage develops. Further, the patient is at risk of bacterial endocarditis. Once the initial echocardiogram reveals no LV dysfunction, the patient may be followed with periodic echocardiograms.

A cardiac catheterization (choice E) would provide the same information as an echocardiogram but would be invasive. At this time, a noninvasive modality is preferred.
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