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Old 10-20-2011
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Default Cardiology

A 31-year-old woman at 27 weeks’ gestation is referred to your office for evaluation of a heart murmur. Her routine physician is concerned because this is a new murmur not present during her last annual examination. Her history and review of systems are unremarkable. Physical examination reveals an afebrile woman with a blood pressure of 115/72 mm Hg and pulse of 80/min. Cardiac examination shows a jugular venous pressure of 7 cm, an S2 that splits with inspiration, and a grade 2/6 systolic nonradiating murmur that is heard best along the left upper sternal border. The rest of her examination is normal. Blood chemistries are unremarkable, erythrocyte sedimentation rate is 38 mm/h, and a complete blood count shows a normocytic anemia with a hematocrit of 33%. Which of the following is the most appropriate next step in management?
A. Reassure her that all is normal
B. Repeat the erythrocyte sedimentation rate (ESR) and complete blood count (CBC)
C. Schedule coronary angiography
D. Send blood cultures
E. Send her for an echocardiogram
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  #2  
Old 10-20-2011
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A. Reassure her that all is normal
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  #3  
Old 10-21-2011
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E. Send her for an echocardiogram
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Old 10-21-2011
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E. Send her for an echocardiogram
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Old 10-21-2011
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Default Answer

The correct answer is A. Almost all pregnant women have volume-related ejection (“flow” or “innocent”) murmurs from an increased blood volume during pregnancy. These murmurs are systolic ejection murmurs heard best along the left upper sternal border and are usually grade 2-3. The murmur may increase as the pregnancy progresses as a result of an increasing cardiac output.

ESR and CBC (choice B) change during pregnancy. Globulins and fibrinogen levels increase when the body responds to inflammation, injury, or pregnancy, resulting in an increased ESR. Further, this patient is anemic. Anemia increases the sedimentation rate. The elevated ESR returns to normal by the third or fourth week postpartum. During normal pregnancy the plasma volume increases by 50%, while the red cell mass increases by only 25%, resulting in a physiologic anemia. These are normal results and do not need to be rechecked until after delivery.

Coronary angiography (choice C) is an invasive test that may be used before valvular surgery to examine the patency of the coronary vessels. This patient is unlikely to have valvular disease or coronary artery disease.

Blood cultures (choice D) should be drawn on patients with fever and a new murmur as part of the diagnosis of endocarditis. This patient is afebrile, has no stigmata of endocarditis, and has no obvious risk factors.

Echocardiography (choice E) is an excellent modality to evaluate heart valves when a suspicious new murmur occurs. It is not indicated for isolated ejection murmurs.
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