USMLE Step 3 - Question 1

A 62 year old male with a history of hypertension, diabetes, rheumatoid arthritis and prior mechanical aortic valve replacement, presents to the emergency department with fevers for 3 days. He denies any chest pains or shortness of breath. His medications include lisinopril, hydrochlorothiazide, aspirin, and coumadin. His temperature is 38.4 C, blood pressure is 160/60, heart rate 100, respirations 20, and oxygen saturation 99% on room air. Physical examination reveals normal lung sounds, a II/IV early diastolic decrescendo murmur at the left lower sternal border, and a very soft S1 heart sound.  Laboratory studies reveal a white blood cell count of 15 thousand and an ESR of 110. A portion of his ECG is below. Which of the following is the most approtriate test to obtain at this time?

Step2-Q11-PIC1

A. Coronary angiography

B. Transthoracic echocardiogram

C. Transesophageal echocardiogram

D. Cardiac magnetic resonence imaging

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