A 22-year-old man comes to the office due to 6 months of exertional shortness of breath. He describes himself as nonathletic and has never engaged in competitive sports. The patient has recently experienced dyspnea on moderate exertion. He also describes a pounding sensation in his head at night. He does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 150/65 mm Hg and pulse is 90/min. No jugular venous distension is present. There is no digital clubbing or cyanosis. The apical impulse is brisk and displaced to the left. A 2/6 continuous murmur is heard below the left clavicle. Upper and lower extremity pulses are prominent and equal. The lungs are clear on auscultation.
If untreated, this patient's risk for which of the following is most increased?

Question

A 22-year-old man comes to the office due to 6 months of exertional shortness of breath.  He describes himself as nonathletic and has never engaged in competitive sports.  The patient has recently experienced dyspnea on moderate exertion.  He also describes a pounding sensation in his head at night.  He does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 150/65 mm Hg and pulse is 90/min.  No jugular venous distension is present.  There is no digital clubbing or cyanosis.  The apical impulse is brisk and displaced to the left.  A 2/6 continuous murmur is heard below the left clavicle.  Upper and lower extremity pulses are prominent and equal.  The lungs are clear on auscultation.
If untreated, this patient's risk for which of the following is most increased?

Quizplus · Accepted Answer

11ec193a_974b_fe0a_853d_f5cb3fbd36e6_MD0002_00 This patient most likely has an unrepaired patent ductus arteriosus (PDA); the prevalence of PDA is increasing due to improved survival rates of premature infants. Small PDAs are typically asymptomatic and may be detected incidentally due to a continuous murmur in the left infraclavicular region.Moderate-sized PDAs often present later with dyspnea and exercise intolerance due to LV failure; wide pulse pressure, bounding pulses, and a laterally displaced apical impulse are characteristically present. With a large PDA, left-to-right shunting typically leads to left ventricular (LV) volume overload (ie, high-output heart failure) in infancy or early childhood, and if untreated can progress to pulmonary hypertension and Eisenmenger syndrome (right-to-left shunting). Small PDAs are typically asymptomatic and may be detected incidentally due to a continuous murmur in the left infraclavicular region. Moderate-sized PDAs often present later with dyspnea and exercise intolerance due to LV failure; wide pulse pressure, bounding pulses, and a laterally displaced apical impulse are characteristically present. With a large PDA, left-to-right shunting typically leads to left ventricular (LV) volume overload (ie, high-output heart failure) in infancy or early childhood, and if untreated can progress to pulmonary hypertension and Eisenmenger syndrome (right-to-left shunting). Patients with unrepaired PDA are at increased risk for infective endarteritis (PDA-related endocarditis), especially if there is associated pulmonary hypertension. Vegetations typically affect the pulmonary end of the PDA and lead to septic pulmonary emboli. PDA closure may be considered in patients who have had PDA-related endocarditis. Procedural antibiotic prophylaxis is recommended for unrepaired PDA if it is complicated by Eisenmenger syndrome or cyanotic pulmonary hypertension. Prophylaxis is also recommended within 6 months after surgical repair with prosthetic material or if there is a residual defect after surgery. antibiotic prophylaxis (Choices A and D) Congenital coarctation of the aorta increases the risk of both aortic dissection and intracranial aneurysm. Patients typically have upper body hypertension and decreased blood flow to the lower extremities. Headaches and epistaxis may be present, and a continuous murmur is common; however, the equal upper and lower extremity pulses in this patient make this diagnosis unlikely. (Choice B) Constrictive pericarditis can occur due to viral pericarditis, radiation therapy, or tuberculosis, but it is not associated with PDA. (Choice E) Mitral stenosis most commonly occurs due to rheumatic fever. PDA does not carry a significant association with mitral stenosis. Educational objective: Symptomatic patent ductus arteriosus (PDA) characteristically presents with left ventricular failure accompanied by a continuous murmur, wide pulse pressure, and bounding pulses. Pulmonary hypertension, and in severe cases Eisenmenger syndrome, can also occur. Unrepaired PDA increases the risk of infective endarteritis that typically affects the pulmonary end of the PDA. __________ References: Large patent ductus arteriosus in an adult complicated by pulmonary endarteritis and embolic lung abscess. (http://www.ncbi.nlm.nih.gov/pubmed/22049313)

A 22-Year-Old Man Comes to the Office Due to 6