A 31-Year-Old Man Comes to the Physician Due to Exertional

question 672

Multiple Choice

A 31-year-old man comes to the physician due to exertional shortness of breath over the last year.  He gets short of breath after running 1-2 miles but feels mostly fine with daily activities.  He has no chest pain, palpitations, or fainting spells.  He also has no past medical history and takes no medications.  There is no family history of sudden death.  His blood pressure is 147/90 mm Hg, pulse is 77/min, and body mass index is 22 kg/m².  The apical precordial impulse is hyperdynamic.  S1 and S2 are normal and a fourth heart sound is heard.  He has a 2/6 systolic murmur at the left sternal border which increases with Valsalva.  The lungs are clear to auscultation.  An echocardiogram shows interventricular septal thickness of 1.8 cm (normal <1.1 cm) and posterior left ventricular wall thickness of 0.9 cm (normal <1.1 cm) .  Left ventricular ejection fraction is 75%.  There is systolic anterior motion of the mitral valve.  At rest, his peak instantaneous left ventricular outflow gradient is 25 mm Hg; however, it is 65 mm Hg after exercise.  Holter monitoring for 24 hours shows no abnormalities.  Which of the following is the best next step in the management of this patient?

• A)Alcohol septal ablation
• B)Amiodarone
• C)Amlodipine
• D)Implantable cardioverter defibrillator
• E)Metoprolol

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Definitions:

Perfect Competitors

describes a market structure where many firms sell identical products, and no single seller has any influence over market price.

Market Price

The current price at which a good or service can be bought or sold in the marketplace.

Shutdown Point

The shutdown point refers to the level of output and price at which a company cannot cover its variable costs, leading it to cease operations temporarily.

Profit Maximizing Level of Output

The quantity of production that yields the highest possible profit for a firm, determined by the point where marginal cost equals marginal revenue.