A 58-Year-Old Man Comes to the Office Complaining of Feeling

question 280

Multiple Choice

A 58-year-old man comes to the office complaining of feeling tired and having poor sleep.  He was diagnosed with myocardial infarction (MI) three months ago and underwent percutaneous coronary revascularization.  According to the patient, it was a "scary and life-changing experience".  He also complains of occasional headaches in the morning, dry mouth, and sore throat.  Sometimes he wakes up in the middle of the night with a choking sensation and pounding in his chest.  He is afraid that he is going to have "another heart attack".  His exercise tolerance is about three blocks and it is limited by weakness and shortness of breath.  He denies any exertional chest pain.
His other medical problems include hypertension, hyperlipidemia, gout, and gastro-esophageal reflux disease (GERD) .  He is a lifetime non-smoker.  His mother suffers from diabetes mellitus.  His father died of a stroke at age 70.  His current medications include metoprolol, rosuvastatin, aspirin, clopidogrel, lisinopril, amlodipine, and esomeprazole.
His blood pressure is 142/86 mmHg and his heart rate is 81/min and regular, and his oxygen saturation is 94% at room air.  His BMI is 39 kg/m².  On physical examination, the heart sounds appear distant.  Lungs are clear on auscultation.  He has 1+ bilateral pitting lower extremity edema to the mid-calf.
Which of the following is the best next step in managing this patient?

• A)Dobutamine stress echocardiography
• B)Polysomnography
• C)Pulmonary function testing
• D)Referral for cardiac rehabilitation
• E)Selective serotonin reuptake inhibitors