USMLE Forum Archives - USMLE Step 2 CK - IM 4
IM 4
TheOne - 10-29-06 15:59
A 46-year-old man with a history of hypertension and hypercholesterolemia visits the physician
for a routine followup. The patient's job involves a lot of traveling, and he admits to
occasionally forgetting to take his medications with him when he travels. He complains of
several episodes of chest pain in the past few months. The pain is sharp in nature, mainly over
his lower chest and epigastrium, and tends to come on when walking. He believes these
episodes are due to indigestion and has been taking antacids. There is a family history of heart
disease, and his father died of a heart attack at age 48. On physical examination, his blood
pressure is 150/80 mm Hg and heart rate is 86/min. His lungs are clear to auscultation.
Cardiac auscultation reveals normal rate and rhythm, without rubs, gallops, or murmurs. There
is no pedal edema. He is sent for an exercise stress test. Five minutes into the test, he
develops ST depression of 3 mm in leads V1-V5. The ST segment depression is greater then
0.12 seconds in duration, and the stress test is stopped. Which of the following is the most
appropriate next step in management?
A. Coronary angiography
B. Holter monitor
C. No further tests are required
D. Repeat stress test with thallium
E. Upper gastrointestinal endoscopy
TheOne - 10-29-06 15:59
A 46-year-old man with a history of hypertension and hypercholesterolemia visits the physician
for a routine followup. The patient's job involves a lot of traveling, and he admits to
occasionally forgetting to take his medications with him when he travels. He complains of
several episodes of chest pain in the past few months. The pain is sharp in nature, mainly over
his lower chest and epigastrium, and tends to come on when walking. He believes these
episodes are due to indigestion and has been taking antacids. There is a family history of heart
disease, and his father died of a heart attack at age 48. On physical examination, his blood
pressure is 150/80 mm Hg and heart rate is 86/min. His lungs are clear to auscultation.
Cardiac auscultation reveals normal rate and rhythm, without rubs, gallops, or murmurs. There
is no pedal edema. He is sent for an exercise stress test. Five minutes into the test, he
develops ST depression of 3 mm in leads V1-V5. The ST segment depression is greater then
0.12 seconds in duration, and the stress test is stopped. Which of the following is the most
appropriate next step in management?
A. Coronary angiography
B. Holter monitor
C. No further tests are required
D. Repeat stress test with thallium
E. Upper gastrointestinal endoscopy
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#3
Yup
TheOne - 10-30-06 18:19 The correct answer is A. This patient has multiple risk factors for atherosclerotic
coronary artery disease: hypertension, hypercholesterolemia, as well as a positive family
history. A stress test is considered positive when there are ST depressions of greater
than 1 mm that last longer than 0.08 seconds or when there is development of
hypotension (10 mm Hg drop in systolic blood pressure) or the appearance of S3 or S4
heart sounds. Patients with positive stress tests require a coronary angiogram as the
next step to assess the need for revascularization.
A Holter monitor (choice B) is used to detect intermittent myocardial ischemia or
paroxysmal arrhythmias. The Holter monitor continuously monitors electrocardiac and
rhythm changes for 24 hours during symptomatic periods. Because ECG changes are
already documented on an exercise stress test, a Holter monitor is not required.
Not performing any further tests (choice C) is not appropriate because he is
symptomatic and has a positive exercise stress test.
Performing a stress test with thallium (choice D) is a more sensitive way of detecting
atherosclerotic heart disease. But because he already has a positive exercise stress
test, repeating the test with thallium is not needed.
An upper gastrointestinal endoscopy (choice E) is performed when reflux or peptic ulcer
disease is thought to be the cause of chest pain.
#5
Re: IM 4 bingousmle - 07-20-10 01:52 ST depression of 3 mm in leads V1-V5 suggests that he has a coronary artery disease and the nest step should be to get an angiography done
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