444 - showman

[ArchivalUser]

A 52-year-old man comes to your office to seek advice about starting an extensive exercise program in preparation for a marathon he plans to run in 10 months. He reports no symptoms of chest pain or shortness of breath. His past medical history is notable for hypertension that has been treated for the past 3 years with amlodipine, 5 mg daily. He also reports smoking 2 packs of cigarettes daily. He is currently sedentary and has not exercised much for the past several years. On examination, he is slightly obese with a blood pressure of 145/93 mm Hg and a pulse of 85/min. His laboratory results are notable for a normal hematocrit, a fasting glucose of 135 mg/dL, and a total cholesterol of 230 m/dL. An electrocardiogram shows normal sinus rhythm and normal axis and intervals, with a good R wave progression. A chest radiograph is clear. Which of the following is the most appropriate management of this patient?
A. Advise against starting the exercise program
B. Encourage the patient to start the exercise program
C. Obtain an echocardiogram to evaluate the left ventricle
D. Obtain an exercise stress test before the training
E. Start the patient on atorvastatin, 10 mg daily

[ArchivalUser]

?D

[ArchivalUser]

whynot E????

[ArchivalUser]

D.

[ArchivalUser]

The correct answer is D. This question highlights the appropriate test for a patient who is middle aged and has cardiac risk factors, before starting an exercise program. This patient is currently asymptomatic but has risk factors including age, high cholesterol, hypertension, possible diabetes mellitus, and tobacco use. Before his proposed exercise program, the patient should be assessed for functional capacity with the help of an exercise stress test.

Initially, advising against the exercise program (choice A) is indicated if the stress test demonstrates ischemia. Cardiac catheterization would be recommended.

Encouraging the patient to start the exercise program (choice B) would have been appropriate if his prior functional status was adequate and he did not have the risk factors indicated. In this case, further assessment of cardiac function is indicated. The risk for an exercise-related cardiac event is low in a healthy individual but higher in those with cardiac disease.

Obtaining an echocardiogram to evaluate the left ventricle (choice C) may be helpful if the stress test is positive, because it may allow delineation of the region at risk. A resting study would not assess functional capacity.

Starting the patient on atorvastatin (choice E) may be necessary. A complete lipid profile must be obtained first, however. Furthermore, the patient could be managed with diet and exercise first, if his stress test was normal.

[ArchivalUser]

it has be D not E coz for starting statin u need LDL which is not given in question,

[ArchivalUser]

Good one! Thanks