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USMLE Step 2 CK Forum USMLE Step 2 CK Discussion Forum: Let's talk about anything related to USMLE Step 2 CK exam


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  #1  
Old 10-20-2011
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Default Cardiology

A 38-year-old woman comes to the clinic for a new-patient visit. She reports no current problems with her health, and is coming to see you only because of a recent change in health insurance plans, which requires her to change providers. Her review of systems reveals some worsening fatigue as well as moderately severe dyspnea on exertion, which has developed insidiously during the previous year. She takes fexofenadine for allergies and sertraline for depression, and adds Ginkgo biloba to her daily smoothie. Past medical history, aside from seasonal allergies and depressive episodes, includes obesity, for which she was treated 2 years prior with a combination of diet, exercise, and fenfluramine and phentermine. She denies smoking or drug use, and is unaware of any diseases that run in the family. After questioning, it appears she is up to date for routine health-screening exams. Vital signs are within normal limits. Cardiac examination reveals a fixed split-second heart sound and a II/VI systolic nonradiating murmur heard best at the left upper sternal border. Extremities reveal 1+ pitting edema bilaterally. Which of the following is the most appropriate management at this time?
A. Cardiac catheterization
B. Echocardiogram with Doppler
C. Exercise stress testing
D. Mammography and Pap smear
E. Reassurance, no abnormal findings
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  #2  
Old 10-20-2011
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is it something related to valvular stenosis caused by fenfluramine??
I'd like to go with B...ECHO n doppler
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Old 10-20-2011
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B. Echocardiogram with Doppler
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  #4  
Old 10-20-2011
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Fixed split S2 is diagnostic for an ASD i would check it with an ECHO with doppler to see the actual volumes.
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Old 10-20-2011
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Default Answer

The correct answer is B. A fixed-split S2 suggests delayed pulmonic valve closure. In a patient with a history of fenfluramine and phentermine (“Fen-Phen”) use, especially given a history of dyspnea on exertion, pulmonary hypertension should be suspected. Fen-Phen, a previously popular drug combination used for weight loss, is associated with valvular disease and pulmonary hypertension. Echocardiography, which can document pulmonary and right-sided pressures, is the first test ordered in the evaluation of suspected pulmonary hypertension. Eventually, cardiac catheterization (choice A) is necessary to accurately document abnormalities.

Stress testing (choice C) is not necessary to evaluate pulmonary hypertension. Regardless of the results of a stress test, the patient would need an echocardiogram and, eventually, a cardiac catheterization. As such, a stress test would add little to the diagnostic workup.

Mammography and Pap smear (choice D) are not necessary in this patient. She is too young to benefit from routine mammography and, if up-to-date with her health care maintenance (as she tells you), likely does not need a Pap smear.

Although a second heart sound may vary with inspiration (physiologic splitting), a fixed-split S2, particularly with risk factors for pulmonary hypertension, is abnormal. Reassurance (choice E) is not a prudent strategy in this patient.
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