Explanation:The correct answer is B. This patient seems to be describing intermittent claudication, which is asign of peripheral vascular disease. Patients often complain of pain during exertion that is relieved byrest. The physical findings in this case are very consistent with this diagnosis. Noninvasive evaluationis usually recommended initially and consists of determining the ratio of ankle to brachial arterial
pressures. The ankle/brachial artery ratio is determined by measuring and comparing the 2 bloodpressures. If the ratio is less than 1 (greater than or equal to 1 is considered normal),peripheral arterydisease is present. After it is determined that peripheral artery disease is present, it is appropriate to advise him to quitsmoking and maintain meticulous foot care (choice A). Additional treatment includes a gradualexercise program and possible aspirin or other antiplatelet drugs. Surgical revascularization is usuallyconsidered for severe, disabling disease.It may be appropriate to recommend daily aspirin therapy (choice C) after you have determined thatperipheral artery disease is present to reduce the risk of cardiovascular events.It is inappropriate to refer him to a surgeon for evaluation for surgical revascularization (choice D) atthis time. You should first perform a noninvasive evaluation before this is even considered.It is inappropriate to schedule angiography of the left leg (choice E) at this time. You should firstperform a noninvasive evaluation before this is even considered. An angiography is not used as aroutine diagnostic study for the initial evaluation of claudication. It should only be performed if surgicalrevascularization is being considered.A 40-year-old man comes to the office complaining of a 3-day history of midsternal chest pain,non-radiating that is worse with inspiration and relieved by sitting forward. He has no past medicalhistory, is on no medications, does not smoke, and has no known drug allergies. He leads an active lifestyle, and had been running about 10 miles a week without problem until a week ago when hedeveloped a “viral syndrome.” His temperature is 38.4 C (100 F), blood pressure is130/70 mm Hg, pulse is 100/min and regular, and respiratory rate is 20/min. He has a high pitched,grating sound that can be auscultated throughout the cardiac cycle over his precordium. An
electrocardiogram shows diffuse ST elevation, diffuse PR depression with PR elevation in lead aVR.The most likely diagnosis isA. anginaB. myocardial infarctionC. pericarditisD. pneumoniaE. pulmonary embolismExplanation:The correct is answer is C. A chest pain that is pleuritic and improves with sitting upand leaningforward is a classic description of the chest pain associated with pericarditis, as is the precordial rubauscultated on physical exam. Diffuse ST elevations with diffuse PR depressions and PR elevation inlead aVR is also the classic description of the EKG findings associated with pericarditis.