WBR0653

Author	PageAuthor::Neeraja Danda M.B.B.S
Exam Type	ExamType::USMLE Step 2 CK
Main Category	MainCategory::Internal medicine
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 35 year old male presents to his primary care physician for shortness of breathe on exertion. Past medical history is significant for ankylosing spondylitis. Physical examination shows high bounding pulse and head bobbing with each pulse. Cardiac auscultation reveals a diastolic decrescendo murmur at the lower left sternal border that increase in intensity on leg raising and squatting. Echocardiography finds a regurgitant aortic valve .Operative criteria for aortic regurgitation includes:]]
Answer A	[[AnswerA::Ejection fraction <55%, left ventricular end systolic diameter >55mm]]
Answer A Explanation	AnswerAExp::Surgery is essential when ejection fraction drops below 55% and left ventricular end systolic diameter is more than 55mm
Answer B	[[AnswerB::Left ventricular end systolic diameter <55 mm, ejection fraction >55%]]
Answer B Explanation	AnswerBExp::'''Incorrect''' Left ventricular end systolic diameter should be more than 55mm and ejection fraction less than 55%
Answer C	AnswerC::Valve replacement is the best choice irrespective of ejection fraction
Answer C Explanation	AnswerCExp::'''Incorrect''' Angiotensisn converting enzyme inhibitors, angiotenisn receptor blockers and nifedipine are the best initial therapy when ejection fraction is more than 55%
Answer D	AnswerD::Surgery should be done in all symptomatic patients
Answer D Explanation	AnswerDExp::'''Incorrect''' Surgery should be performed only when appropriate criteria is met, not in all symptomatic patients. Medical treatment is the best initial therapy.
Answer E	[[AnswerE::Ejection fraction <60%, left ventricular end systolic diameter >40mm]]
Answer E Explanation	[[AnswerEExp::Incorrect Ejection fraction <60%, left ventricular end systolic diameter more than 55mm is the operative criteria for mitral regurgitation, not aortic regurgitation]]
Right Answer	RightAnswer::A
Explanation	[[Explanation::Aortic regurgitation can be caused by reactive arthritis, ankylosing spondylitis, marfans syndrome and syphilis. Features of aortic regurgitation include diastolic decrescendo murmur at lower left sternal border, head bobbing with each pulse, Capillary pulsations in the finger nails, murmur over femoral artery , and high bounding pulse. . Transthoracic echocardiogram is the best initial diagnostic test for all valvular diseases. In aortic regurgitation angiotensisn converting enzyme inhibitors, angiotenisn receptor blockers and nifedipine are the best initial therapy but surgery is when ejection fraction drops below 55% and left ventricular end systolic diameter is more than 55mm. Educational Objective In aortic regurgitation angiotensisn converting enzyme inhibitors, angiotenisn receptor blockers and nifedipine are the best initial therapy but surgery is essential when ejection fraction drops below 55% and left ventricular end systolic diameter is more than 55mm. References Page 64,66 Master the boards step 3 2009 edition, Page 91 Master the boards Step2 CK second edition Educational Objective: References: ]]
Approved	Approved::Yes
Keyword	WBRKeyword::Aortic regurgitation, WBRKeyword::Operative criteria, WBRKeyword::End diastolic diameter, WBRKeyword::ejection fraction
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::