Q101) A 65 y/o man with presents to your office with complaints of exertional chest pain for the past 4 weeks. The chest pain is usually left sided, occurs on walking about one block and goes away with rest. He denies any chest pain now. He also reports no change in quality or intensity of his chest pain He also reports having been diagnosed with peripheral arterial disease about 2 months ago for which he was advised exercise therapy. He does experience leg pain on walking about one block which also improves with rest. His past medical history is significant for moderate COPD, Hypertension and a hernia repair about 3 years ago. His medications include lisinopril, hydrochlorthiazide and tiotropium inhaler. Physical examination is benign. The next best step in establishing the diagnosis in this patient is :
A) 2 D -Echocadiogram
B) Exercise Stress Test ( Treadmill Stress Test)
C) Dobutamine Stress Echocardiogram
D) Persantin Stress Test
E) Cardiac Catheterization
Archer USMLE Step 3 Blog 
C
D
d
CC
c
C) Dobutamine stress test
C
cause COPD
c
c.Dobutamine stress Echocardiogram
***Persantine causes Bronchospam-Contraindicated in COPD
c
B exercise stress test
COPD is a factor which favoring the Myocardial perfusion imaging, so the answer i……D
Simple and humble, the guy can walk for 1 block and the pain is relieved with rest. There’s no dyspnea at rest and the patient is not having pain at present. He can walk a block with no problems, i would go for Excercise treadmill no persantine or dobutamine needed!
Answer B
yup exercise stress test first.if patient heart rate cannot go above 85% of target than proceed with dobutamine stress test.
answer is C, patient has PAD presenting with intermittent claudication, so ETT is not indicated, he also has COPD so persantine nuclear imaging is contraindicated due to bronchospasm, patient needs dobutamine stress echo to assess for CAD
C. Always check out most recent guidelines, indications and absolute/relative contraindications if you dont know the answer for sure.
C if you want the point on usmle
B is the answer.
He has COPD and PAD…doesnt that warrant for an echo test. Basically, wouldnt you opt for a dobutamine stress test given his COPD and PAD may limit him from exercising?