Master the board step 3

Master the Boards: USMLE Step 3
Which of the following is an absolute contraindication to the use of beta blockers?
a. Symptomatic bradycardia
b. Peripheral artery disease
c. Asthma
d. Emphysema
e. Diabetes
Answer: A. Symptomatic bradycardia is an absolute contraindication for the use of beta
blockers. The overwhelming majority of patients with peripheral artery disease can still use
beta blockers. In a patient with a myocardial infarction, the mortality benefit of metoprolol
far exceeds the risk of its use when asthma, emphysema, or peripheral artery disease is
present. Two thirds of asthma patients can tolerate beta blockers.
Valvular Heart Disease
All valvular heart disease presents with shortness of breath as the chief complaint.
Look for the phrase “worse with exertion or exercise.” Hypertension,
myocardial infarction, ischemia, increasing age, and rheumatic fever will be in
the history but, with the exception of rheumatic heart disease, are probably too
nonspecific to give you the diagnosis. Young patients with valvular heart disease
will have mitral valve prolapse, hypertrophic obstructive cardiomyopathy,
mitral stenosis, or bicuspid aortic valves.
Following are clues to the diagnosis:
Clue to Diagnosis
Young female, general population
Healthy young athlete
Immigrant, pregnant
Turner’s syndrome, coarctation of
aorta
Palpitations, atypical chest pain not
with exertion
Likely Diagnosis
Mitral valve prolapse
Hypertrophic obstructive
cardiomyopathy (HOCM)
Mitral stenosis
Bicuspid aortic valve
Mitral valve prolapse
Physical Findings
All valvular heart disease can be expected to have murmurs and rales on lung
exam. Possible findings on exam are as follows:
··
Peripheral edema
··
Carotid pulse findings
··
Gallops
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