Interactice MCQ (2)

[The reader]

Welcome to another interactive MCQ.

The real benefit of this exercise is to expose your knowledge and stimulate further learning. If you work on any formation by deep thinking, asking about it and reading around it it will stay as roots in your brain. Compare this to a superficial learner who wants to memorize information to vomit(sorry!) it in the exam!!

Now, let's deal with this case:


A 52 year old women is evaluated because of 6-week history of substernal chest pressure that occurs with excercise, especially in the mornings, lasts 10-15 minutes, and resolves with rest. The pressure radiates to her shoulders but is not accompanied by shortness of breath, headches, diaphoresis, nausea, or vomiting. The episodes occur every 3 to 4 days and have caused her to reduce her activity level.

On P/E, BP 120/80, HR 80/ min and regular. The lungs, heart, abdomen, and peripheral pulses are normal. Hb 12g/dl. The resting ECG is normal.

What is the best next diagnostic step in this patient?

(A) Stress electrocardiogram
(B) Stress electrocardiogram with thallium imaging
(C) Dipyridamole stress test with thallium imaging
(D) Coronary angiography
(E) Dobutamine stress echocardiogram


What is your response and why? Justify your answer.

Good luck

[WaLeeD]

AssaLaMu3LaiKuM..

Welcome back our dear THE READER..
Surely since now and on..
We will try to change our learning skills as much as we can..
Thanx


UmmMm..
Well.. I think that choice A is the next step..
because as we conclude from the findings that:
This chest pressure is not of GI origin.. nor of Respiratory tract..
It might be cardiac or any other not known cause..
Her vital signs and cardiac activity are in the normal reange..

I'll exculde the cardiac cause to some extent..
Although the pain rdiates to the shoulder ( a feature of anginal pain)
But other cardiac signs and symptoms are all normal



And as we know that stress and anxiety are one of chest pain causes..
Hence it is written pressure rather than pain..

So I'll go for what is simple and not painful to pt..
I'll do stress ECG to exclude or include the strss as a cause..
and if it is alright..
Then I'll go for coronary angiogaphy..
puting in mind that it might be a pre-anginal case..

I hope that Ill be right..
thanx
:LL:

[reda0007]

Assalmu Alykom

thank u dr Almualim for continuing

okay ,,, i got to confess now I am in love with Cardiology

so thank you for discussing this cardiac case :wooow:

Unfortinatly ,, i am not quite informed about the details of investigation for cardiac patint but still

Anyway

can discuss briefly

what i have figured out from this case that it is

a stable angina case

the patient vital signs was normal almost ,, as i can see

Hb level was good ... anemia was excluded

anyway

seems that it is the start of coronary Insufficiency

so ..... as i love to be < Not Invasive >

I will let the angiography as a last choice while it is the gold standard

and as i have read that thalium imaging is giving a good impression about the cardiac perfusion

i will choose ( b )

ofcourse exercise ECG is certainly indicated at this case

but thalium imaging would give also good information

Echo - according to my information - is required to evaluate the patient with Heart failure .... iam not sure ,,,, but i will not use it here

Hope i have discussed the case fully

Thanx

[The reader]

Salam:
I am posting this reply without putting my password. is this normal?

I was expecting more responses to this question.

The main objective of this question is to test your understanding of the diagnosis of coronory heart disease (CHD). The patient is presenting with a classical effort induced angina and our aim as clinicians is to first diagnose (CHD) and at the same time risk stratify pt (that means are they on the high or low risk for developing cardic events, that means, should you preceed with coronary angiogram and stenting if they are at high risk or should you just treat the pt medicaly if he is at low risk...always remember this in cardiology RISK STRATIFICATION).

back to our pt
The best initial diagnostic workup is exercis ECG. this is a cost effective modality. it a recommendation AHA ( American Heart Assocoation ) for chronic stable angiana. therefor, option A is the correct answer and waleed is correct. There are certin features in exercis ECG that would straify pt as high oe low risk.

The two most important features in this pt that made exercis ECG the test of choice are 1- his ability to exercis 2- normal baseline ECG
if these two or one condtion is absent the test of choice would be a pharmacological stress testing not angiogram

There are a lot that could be said regarding these tests. I hope that i inspired you to read more about them.

Thank you and looking forward to your comments.

[NigHTmArE]

i read this topic and realized i was late...

but really im impressed with the interactive MCQ method

keep up the good work Reader and hopefully i'll catch ya another time

[dr_messo]

Ummm

once i read thr Q

i choosed A

cuz its the best cost effective next step


but later on i noticed that i am late & the answer is written down by dr.Hani


any way


next time inshallah

[WaLeeD]

SaLaaAm


You are welcome dear..
Although my approach to the Q was wrong..
I choosed the right answer from my simple information about chest pain..
But of course i've understood the stress wrongly..
I thought that stress= psychological stress..
But it is exercise induced stress to the heart..


:LL:


Thanx dear..
Looking for more ..

[Dr.wrood2004]

my choosen answer was A before i read the right answer ..

dr .hani

thanks so much for this interacive session..

we aplogize for beign late ....


but we will follow the next inshallah ...


best regards