A 60-Year-Old Man Comes to the Physician for Follow-Up 8

question 536

Multiple Choice

A 60-year-old man comes to the physician for follow-up 8 weeks after coronary artery bypass graft surgery.  Although his exertional chest pain is improved since surgery, he is short of breath when walking briskly.  He also complains of orthopnea that has worsened since the surgery.  The patient has no fever, chills, cough, weight loss, or chest pain.  His medications include aspirin, atorvastatin, metoprolol, amlodipine, and albuterol/ipratropium as needed.  He is an ex-smoker with 20-pack-year history.
His blood pressure is 134/87 mm Hg, pulse is 57/min, and respirations are 14/min.  His oxygen saturation on room air is 96% while sitting and 90% while supine.  His body mass index is 31 kg/m².  Physical examination shows a middle-aged man in no acute distress.  Jugular venous pressure is estimated at 6 cm H₂O.  Lung examination is notable for decreased breath sounds at the left base with dullness to percussion.  Cardiac examination shows a 2/6 mid-systolic murmur at the right sternal base and normal second heart sound.  The surgical wound is well apposed and clean.
Chest x-ray reveals a raised left hemidiaphragm and mild scarring of the right lung base.
Spirometry in the upright position shows forced expiratory volume in 1 second of 69% of predicted, forced vital capacity of 70% predicted, and FEV₁/FVC ratio of 0.98.  Spirometry performed in the supine position shows forced vital capacity of 59% of predicted.
Which of the following is the best test to diagnose the cause of this patient's dyspnea on exertion?

• A)Exercise echocardiography
• B)Fluoroscopic "sniff" test
• C)High-resolution computed tomography scan of the chest
• D)Serum pro-brain natriuretic peptide levels
• E)Transesophageal echocardiography

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Definitions:

Development

The process of change and growth throughout the life span, including physical, cognitive, psychological, and social aspects.

Late Adulthood

The stage of life typically associated with old age, focusing on retirement, physical decline, and reflecting on life achievements.

Retirement

The act of leaving one's job and ceasing to work, typically due to reaching a certain age or health condition, often leading to changes in lifestyle.

Career

involves a series of jobs or occupations undertaken over a period of time, often in a specific industry, that provides progression and personal livelihood.