CLICKER QUESTION

Question :

JT is a 63 year old female who presents to her physician with complaints of fatigue and shortness of breath on exertion, both of which are progressively worsening.  She reports no chest pain, cough, or peripheral swelling.  Her physical examination findings include a normal pressure, a normal and regular heart rate, and decreased radial pulses.  Her lung exam is normal.  Auscultation of her heart reveals a loud S1, no third heart sound, an opening snap, and a low pitched diastolic murmur that is heard most prominently at the apex of the heart.  An echocardiogram reveals a pressure gradient between the left atrium and ventricle of 10 cm of water.

Given the history, physical findings, and findings on echocardiogram, considered the diagnosis.  Which of the following would be the preferred treatment for this patient?

a.       Mitral valvuloplasty

b.      ACE inhibitor therapy

c.       Mitral valve surgery

d.      Aortic valve surgery

The purpose of my question was to stimulte cognitive processes. Students must consider all of the patient’s signs and symptoms, think through the differential diagnosis, then determine the most likely diagnosis. Then the list of answers are the possible  treatments. There is only one right answer. What I decided to change is to add another possible answer: e. none of the above. The reason is that if they reached the incorrect diagnosis, none of the answers would be correct. This would allow them to consider the characteristics of the true diagnosis, and the clinical difference between their proposed diagnosis and the true diagnosis.