American College of Physicians: Internal Medicine — Doctors for Adults ®

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The MKSAP Challenge

From the January-February ACP Observer, copyright © 2005 by the American College of Physicians.

A 29-year-old woman in the 28th week of pregnancy has a 2-hour history of sudden onset, severe anterior chest pain radiating to her back. She has a 10-year history of mitral valve prolapse. Her family history is unremarkable.

On physical examination, blood pressure is 105/78 mm Hg, heart rate is 110/min, and respiration rate is 18/min. She has a high arched palate, diminished S1, a soft, early diastolic murmur best heard along the left sternal border, and a midsystolic click and a late systolic murmur. Abdominal examination shows a gravid uterus. The remainder of the physical examination is normal.

An electrocardiogram shows only mild T-wave flattening.

Which of the following is the most appropriate diagnostic test?

A. Serum troponin measurement
B. Transthoracic echocardiogram
C. Magnetic resonance angiography
D. Transesophageal echocardiography
E. Helical computed tomography scan

Answer

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