USMLE Step 3 - Question 1

A 62-year-old man with a history of hypertension, diabetes, rheumatoid arthritis and prior mechanical aortic valve replacement, presents to the emergency department with fever lasting 3 days. He denies any chest pain or shortness of breath. His medications include lisinopril, hydrochlorothiazide, aspirin and coumadin. His temperature is 38.4 °C, blood pressure is 160/60 mmHg, heart rate is 100 bpm, respirations 20, and oxygen saturation is 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 15,000 and an ESR of 110. A portion of his ECG is below. Which of the following is the most appropriate test to obtain at this time?

Step2-Q11-PIC1

A. Coronary angiography

B. Transthoracic echocardiogram

C. Transesophageal echocardiogram

D. Cardiac magnetic resonance imaging

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