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)