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MMLU / A 78-year-old man, who underwent coronary angiography with stent placement 8…

Problem

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question

A 78-year-old man, who underwent coronary angiography with stent placement 8 years ago, comes to the office for a routine health maintenance examination. The patient reports no new symptoms except for shortness of breath and fatigue during exercise that began 3 months ago when he tried to increase the distance of his daily walk from 1 mile to 3 miles. He has not had orthopnea, paroxysmal nocturnal dyspnea, or chest pain. Additional medical history is significant for hypertension, coronary artery disease, dyslipidemia, and polymyalgia rheumatica. The patient also has a heart murmur that was discovered at an armed forces screening physical examination at age 18 years, but it did not prevent him from serving in the military. Medications are metoprolol, atorvastatin, lisinopril, omeprazole, and a low dose of prednisone every other day. The patient is active and manages a small farm. BMI is 26 kg/m2 . Vital signs are temperature 37.0°C (98.6°F), pulse 60/min, respirations 18/min, and blood pressure 124/61 mm Hg. Cardiac examination discloses a normal S1, pronounced S2, and a grade 2/6 late systolic murmur heard at the right upper parasternal border. Pulses are normal in contour. Results of laboratory studies are within the reference ranges. ECG shows no abnormalities. Which of the following is the most appropriate next step in management?

choices

  1. Decrease the dose of metoprolol
  2. Increase the dose of prednisone
  3. Obtain serum vitamin D concentration
  4. Order a transthoracic echocardiography

subject

professional_medicine

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Source and history

task_id
3ce19a98-c42a-5414-b7a3-ec375cfb4082
task_key
all--test--3ce19a98-c42a-5414-b7a3-ec375cfb4082
task_revision_id
1
config / split
all / test

Official source

initial import