Question

For the past 2 months Mr. S has been experiencing progressive worsening exertional chest pain, so he presented to his friendly and knowledgeable NP for evaluation. His physical examination was normal, vital signs are: BP 126/66mmHg, HR 68bpm, and he is otherwise healthy without chronic illness. At 49 years old he has no history or family history of heart disease, diabetes or hypertension. He does not drink heavily or smoke cigarettes. In fact, he follows a healthy diet and exercises regularly. He has a low probability of coronary artery disease. You do an EKG in your office that shows normal sinus rhythm with no acute changes.

Please bullet-point your answers and rationales to the following questions:

Which of the following tests would you order FIRST to evaluated his symptoms: Transthoracic (surface) echocardiogram, treadmill exercise stress test, nuclear stress test, diagnostic cardiac catheterization)? (5 points).

Explain why you chose this test first, and why each of the other three would not be appropriate. At what point, or with what patient type, would each be appropriate? (10 points).

If this chosen test proves to be abnormal, suggesting possible coronary disease, what would your next diagnostic step(s) be? Please explain your rationale(s)? (5 points)

Answer 1

The first test which could be ordered to rule out his chest pain is a transthorasic or surface echocardiogram.

This is a non invasive procedure, generally recommended to assess the heart's ability to pump blood and its blood supply.If the problem is associated in relation to this ,Echo can rule put the cause of chest pain easily

The treadmill exercise test can be performed in a healthy person to rule out ischemia not in a patient whi has progressive chest pain.If done can aggravate the state and cause fatal events

Nuclear stress test is the least choice as the incidence of CAD is very less

Diagnostic cardiac catheterization is the last choice to rule out the cause if chest pain as it is an invasive procedure

If the test is positive for CAD in Echo, the next test suggested is cardiac catheterization, to assess the blockages and relieve it by angioplasty or stent.It bot only acts as a diagnostic test but also acts as a procedure to relieve the symptoms with certain measures.