View source for WBR0837

{{WBRQuestion
|QuestionAuthor=Neeraja Danda M.B.B.S
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A 50 year old male presents to his physician’s office complaining of occasional burning chest pain for the last 3 months. The pain often starts after eating food, but is not always related to food. He has a history of hypertension for the last 10 years and is on medication. His father died of heart attack at the age of 68. He works as manager in a bank and does not exercise.What is the most appropriate next step in the management of this patient?

|Explanation=50 year old male with a family history of ischemic heart disease with sedentary life style and a history of hypertension complaining of chest pain mostly points towards heart related chest pain as he has some risk factors. Even though the question states pain is related to food intake he definitely needs an electrocardiogram first to rule out ischemic heart disease. If the electrocardiogram shows no abnormality we might want to think about gastrointestinal related pain and prescribe pantoprazole and see how he responds. But in this case always rule out ischemic heart disease first by opting for electrocardiogram.

'''Educational Objective:''' The initial test in case of chest pain depends on patient’s age and the presence of risk factors for heart disease. In this case initial test of choice must be electrocardiogram to rule out heart disease.

'''References:''' Page 42 Master the boards Step 3 2009 
|AnswerA=Gastrin levels

|AnswerAExp='''Incorrect''' We may need Gastrin levels if we are suspecting Zollinger Ellison syndrome but not in this patient.
|AnswerB=Electrocardiogram
|AnswerBExp=Electrocardiogram must be performed first to rule out heart disease in this patient.
|AnswerC=Stomach Acid test
|AnswerCExp='''Incorrect''' It is sometimes performed to know the amount of acid in the stomach in cases of Ulcer in the gastrointestinal system
|AnswerD=Lipid levels
|AnswerDExp='''Incorrect''' Lipid levels Lipid levels are important in this patient to decrease the future risk of atherosclerosis but not as the next step here.
|AnswerE=Prescribe Pantoprazole 
|AnswerEExp='''Incorrect''' Pantoprazole can be prescribed if Electrocardiogram result is normal. Acid reflux may be the most probable cause of this patient’s distress, but pantoprazole therapy without ruling out ischemic heart disease first is not the most appropriate course of action
|RightAnswer=B
|WBRKeyword=Elactrocardiogram, Myocardial infarction, 
|Approved=Yes
}}