In aortic stenosis, which one of the following associated conditions carries the worst prognosis?
Correct Answer A: Before the onset of symptoms, survival in patients with aortic stenosis is similar to that of the normal population, and sudden death is rare. When the classic symptoms develop, however, survival declines precipitously. Approximately 35% of patients with aortic stenosis present with angina and 50% die within 5 years without valve replacement. Of the 15% who present with syncope, 50% die within 3 years unless the valve is replaced. And of the 50% of aortic stenosis patients who present with congestive heart failure, 50% die within 2 years without valve replacement. The annual risk for sudden death in patients with symptomatic aortic stenosis ranges from 10% with angina patients to 15% in patients with syncope and 25% in patients with congestive heart failure. Pernicious anemia is a treatable disease not associated with aortic stenosis.
In summary, in patients in whom the aortic valve obstruction remains unrelieved, the onset of symptoms predicts a poor outcome with medical therapy. The approximate time interval from the onset of symptoms to death is 1.5-2 years for heart failure, 3 years for syncope, and 5 years for angina.
A 76-year-old female is presenting to the ED with progressive exertional dyspnea and peripheral edema. She has a long standing history of hypercholesterolemia (controlled with statins), and a 30 pack year smoking history. A TEE is performed and reveals aortic stenosis, with an area of 0.67 cm2, LV and LA dilatation. Her LV end systolic diameter is 60mm, and her LVEF is 49%. She has a JVD > 4cm above the horizontal.
Which of the following would best treat the patient's heart condition?
Correct Answer E: When a patient presents with an aortic area of less than 0.7cm2, aortic valve replacement (choice E) is warranted. This is the best definitive treatment for the patient's heart condition.
→ Furosemide (choice A) would be a good initial treatment for edema relief, but it is not the best treatment for this patient. Choose furosemide if the question is asking initial symptomatic relief treatment.
→ Metoprolol (choice B) is used in a patient with aortic stenosis complaining angina. In this symptomatic patient with an aortic area < 0.7 cm2, definitive treatment is aortic valve replacement and this is what the question is asking.
→ Lisinopril (choice C) can be attempted in a patient with pulmonary congestion; however, this is not the definitive treatment this question is asking.
→ Aortic balloon valvuloplasty (choice D) is used as a palliative measure in critically ill adult patients who are not surgical candidates or as a bridge to aortic valve replacement in critically ill patients. The high rate of restenosis and the absence of a mortality benefit preclude its use as a definitive treatment method.
The most serious complication of a slipped capital femoral epiphysis is:
Correct Answer C: Avascular necrosis is the most serious complication of a slipped capital femoral epiphysis, and leads to more rapid arthritic deterioration. It may require hip fusion and total hip replacement early in adulthood.
Which one of the following eye operations involves creation of a corneal flap with ablation of a precise amount of corneal stroma, without sutures?
Correct Answer A: Refractive surgeries have become commonplace, and are used to correct myopia and hyperopia. The LASIK procedure creates a corneal flap and ablates part of the corneal stroma with no sutures. RK and PRK involve radial incisions to change the shape of the cornea. LTK uses a laser to shrink the cornea to change the shape. With ICR a plastic ring is placed into the cornea to change its shape.
You discovered a 10 cm enlarging hematoma adjacent to the episiotomy site in a patient whose baby you delivered 6 hours ago.
The best management at this time is:
Correct Answer B: Enlarging postpartum hematomas adjacent to an episiotomy are best treated by removing the sutures and ligating the specific bleeding sites. A perineal pad and cold compresses and inadequate for an enlarging lesion, and hypogastric artery ligation and hysterectomy are indicated only with supravaginal hematomas.
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