USMLE Forum Archives - USMLE Step 2 CK - IM 45
IM 45
TheOne - 06-25-07 14:23
A 20 years old professional dancer complains of several episodes of near loss of consciousness during a performance. She has been in excellent health and is a principal dancer in the New York City Ballet Corps. She has no family history of coronary artery disease. She does not smoke, and a recent cholesterol profile was normal. On physical examination, her blood pressure is 145/90 mm Hg, and her pulse is 94/min and regular. She has a brisk carotid upstroke with a double impulse palpable. She has a loud S4 and a harsh systolic murmur heard along the left sternal border. The murmur is accentuated during the Valsalva maneuver. An electrocardiogram reveals severe left ventricular hypertrophy. Which of the following is the most appropriate medication in the management of this patient?
A. Captopril
B. Digoxin
C. Diltiazem
D. Furosemide
E. Propranolol
TheOne - 06-25-07 14:23
A 20 years old professional dancer complains of several episodes of near loss of consciousness during a performance. She has been in excellent health and is a principal dancer in the New York City Ballet Corps. She has no family history of coronary artery disease. She does not smoke, and a recent cholesterol profile was normal. On physical examination, her blood pressure is 145/90 mm Hg, and her pulse is 94/min and regular. She has a brisk carotid upstroke with a double impulse palpable. She has a loud S4 and a harsh systolic murmur heard along the left sternal border. The murmur is accentuated during the Valsalva maneuver. An electrocardiogram reveals severe left ventricular hypertrophy. Which of the following is the most appropriate medication in the management of this patient?
A. Captopril
B. Digoxin
C. Diltiazem
D. Furosemide
E. Propranolol
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#1
Re: IM 45 jwang - 06-26-07 02:03 This is a hard question, she sounds like she has a dilated cardiomypoathy. All of the drugs listed can be used i believe. But the only one shown to improve long term survival is an ACEI. So I will pick A. captopril.
#2
Re: IM 45 nrp - 06-29-07 12:25 E.Propranalol.The patient is having Hypertrophic cardiomyopathy.In HOCM, the murmur increases with standing and valsalva's where blood returning to the heart is decreased.The murmur decreases when the blood returning to the heart is increased.Propranalol is the useful medication in this condition
#4
Re: IM 45
TheOne - 07-08-07 14:15 The correct answer is E. This patient has the presentation of idiopathic hypertrophic subaortic stenosis, which is a frequent cause of syncope or near syncope in young patients. She has a characteristic murmur, which can be distinguished from other systolic murmurs by its increase with the Valsalva maneuver. Any maneuver that acts to decrease left ventricular size will increase the murmur of idiopathic hypertrophic subaortic stenosis because the obstructive component increases as the left ventricular cavity shrinks. Beta-blockers, such as propanolol, help relax the left ventricular smooth muscle and reduce ventricular outflow obstruction.
The angiotensin converting enzyme inhibitor captopril (choice A), the cardiotropic agent digoxin (choice B), and the diuretic furosemide (choice D) are variably effective in patients with dilated cardiomyopathy. However, they are potentially harmful in a patient such as this, who already has a hypertrophic ventricle and increased ejection fraction. Diltiazem (choice C), a calcium channel blocker, has lesser effects than propranolol on the relaxation of ventricular smooth muscle.
#5
Re: IM 45 bingousmle - 06-20-10 08:29 the dancer has hypertrophic obstructive cardiomyopathy with a loud S4 and a harsh systolic murmur heard along the left sternal border..give her BB
#6
Re: IM 45 babbu5508 - 06-20-10 13:53 the girl most likely has an aortic stenosis due to hypertrophic obstructive cardiomyopathyoud S4 and a harsh systolic murmur accentuated by valsalve.....beta blockers to be used.
#8
Re: IM 45 bingousmle - 06-30-10 17:51 its also important to avoid digoxin in HOCM as well as spironolactone which is used in other types of heart failure.. beta blockers and diuretics are the mainstay of therapy
#9
Re: IM 45 babbu5508 - 07-10-10 03:34 E. Propranolol..the most important treatment in a patient with hypertrophic obstructive cardiomyopathy would be beta blockers.
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