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A 67-year-old, 220-pound female presents to your family practice office for a presurgical clearance examination for a total hip replacement in one week. Past medical history includes hypertension, atrial fibrillation, a prior percutaneous transluminal coronary angioplasty (PTCA) with drug-eluting stent seven months ago, and type 2 diabetes mellitus . Her medication include: lisinopril, metoprolol ER, a baby aspirin, clopidogrel, and metformin. Her blood pressure is 128/78 mm Hg, pulse is 72 beats/min, temperature 98.6°F, and respirations of 17 breaths/min. Her heart and lung sounds are normal. The abdominal examination is benign. Her x-ray and EKG are normal, as are all required labs. Which of the following is recommended for this patient prior to her surgery?
A. Discontinue metoprolol one week prior to surgery.
B. Discontinue metformin one week prior to surgery.
C. Discontinue the aspirin and clopidogrel five to seven days prior to surgery. The answer is B.
EXPLANATION: Allergen-specific serum IgE testing is an easy and accurate method for determining the presence of atopic allergy, and with newer in vitro technology available, in vitro testing is at least equivalent to skin testing in efficacy. In vitro assays are safe, specific, cost-effective, and reproducible, and do not require the patient to be free of antihistamines and other medications that may interfere with skin testing. They are also easy and quick and are therefore preferred, especially in children and in anxious patients.
Although the original in vitro assay, the RAST test (radioallergosorbent test), is no longer performed, its name is still used today to generally describe IgE-specific blood testing. However, not all in vitro assays available today are alike. The newer assays tend to be faster, more reliable, and more efficient than previous tests. The ImmunoCAP is an excellent example of this newer technology. Not using a reliable assay may affect the diagnosis of atopy and therefore the prescribing of appropriate therapy
In vitro testing can be cost-effective if an appropriately chosen inhalant screening battery of 10 to 12 allergens consisting of the most prevalent pollens, molds, dust mites, and animals in the local environment is used. In children, common allergenic foods are substituted or added. No further testing is necessary if this battery is negative. If the screening battery is positive and if no immunotherapy is considered, additional allergy testing can be performed. The answer is D.
EXPLANATION: Clostridium botulinum produces a neurotoxin that can lead to life-threatening illness including respiratory paralysis. Botulism infection is caused by the spore-forming bacteria that lives in soil and can be foodborne. In the latter case, home-canned foods are often the cause. After a 12-hour to 3-day incubation period, botulism begins with classic symptoms of abdominal pain, nausea, vomiting, and mild diarrhea and, if unchecked, evolves into a progressive neurologic disorder marked by double vision, motor weakness, and ptosis. Respiratory muscle involvement may occur ultimately and result in death. Because of the virulence of the neurotoxin it has been used as an agent of bioterrorism. Cholera and enterotoxigenic E. coli cause a foodborne diarrheal illness that can result in significant morbidity and mortality, but they do not have neurologic manifestations. Pinworm infection is usually found among younger children, is marked by severe anal itching, and fecal-oral transmission. A 57-year-old man with a history of HTN, hyperlipidemia, and chronic tobacco use presents to the emergency department with complaints of worsening chest tightness over the last 2 months. He initially noticed that every time he raked leaves, he had a few minutes of chest tightness, which was relieved within 5 minutes if he rested. He now notices that raking will precipitate severe chest discomfort, diaphoresis, and dyspnea, which lasts for 20 minutes even if he rests. Last night, while watching football, he again noticed chest tightness, which began suddenly and slowly dissipated over 15 minutes. His physical examination is normal. An EKG performed during an episode of chest discomfort demonstrates normal sinus rhythm at 90 bpm with ST-segment depression. Beta blockers, IV nitroglycerin, aspirin, and oxygen are started. Serial troponin levels are negative. A repeat EKG continues to demonstrate ST segment depression, along with t-wave inversion. The patient's chest discomfort is decreased in intensity and duration, but returns periodically. Which of the following is the most appropriate next step in the management of this patient?
A. Cardiac catheterization
B. Exercise nuclear stress test
C. Holter monitor
D. Tilt table test
E. Transesophageal echocardiogram The answer is A.
EXPLANATION: In patients with unstable angina pectoris, if symptoms and EKG changes are not stabilized with appropriate medical therapy, including beta blockade, aspirin, oxygen, and nitroglycerin, then choice A, cardiac catheterization, with likely percutaneous coronary intervention, would be recommended, as this patient is at high risk for acute myocardial infarction. Choice B, exercise nuclear stress testing, would provide information regarding exercise tolerance and exercise-induced dysrhythmias, as well as regarding myocardial ischemia, but in this unstable patient, it would not be recommended. In patients whose conditions stabilize with medical therapy, nuclear stress testing is a viable option. The answer is E.
The correct choice is E, radioactive iodine. This is the treatment of choice in the elderly because it is efficient, easy to take, and inexpensive. Choice A, beta blocking agents, are useful in the treatment of symptoms of hyperthyroidism, such as palpitations, but they are not a definitive treatment for the disorder. Choice B, levothyroxine, is used for thyroid hormone supplementation in patients with hypothyroidism. Choice C, methimazole, is an anti-thyroid drug that has increased toxicity in the elderly and is more useful in younger patients with mild hyperthyroidism. Choice D, total thyroidectomy, has a limited role as a treatment for hyperthyroidism, and is associated with increased morbidity in the elderly. The answer is D.
EXPLANATION: The major risk factors for HIV infection in American women are intravenous drug use (33%) and heterosexual contact with an infected partner (65%). Thanks to universal blood donor screening using the HIV ELISA, antigen, and viral load testing, the risk for any person contracting HIV from a screened unit of blood is only 1:1,000,000. The risk for any person following a needle-stick injury is about 1:300 with deeper sticks, hollow bore needles, visible blood on the needle, and advanced stage of disease in the source increasing the risk. HIV infection puts a woman at increased risk for gynecologic complications such as pelvic inflammatory disease. Unlike the use of latex condoms, the use of oral contraceptives does not protect against HIV transmission, but is not, per se, a risk factor for HIV infection. A 44-year-old female presents to the emergency department with a right-sided headache. She states the headache is located on the right temple region, is non-radiating, and does not cause photophobia. She is otherwise healthy and has no reported medical problems. She only takes acetaminophen for the pain, which has minimal relief. On physical exam she is alert, awake, and oriented. Her vitals are T 98.8, P 78, R 18, and BP 128/76. Her head is normocephalic, atraumatic, and pupils are equal and reactive. She has tenderness to the right temporal area of the temporal artery, and there is no noted swelling, redness, or abnormalities noted. There is no tenderness to the cervical muscles. She exhibits a non-focal neurological exam. Based on the description, what is the most likely diagnosis of this patient?
A. Migraine headache
B. Tension headache
C. Cluster headache
D. Temporal arteritis A 76-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 1. His echocardiogram demonstrates normal LV systolic function and normal valvular function. Which of the following would be considered the most appropriate long-term anti-coagulation therapy for him?
Pic- afib
A. Plavix 75 mg daily
B. Aspirin 325 mg daily
C. Plavix 75 mg daily and Aspirin 81 mg daily
D. Warfarin 5 mg, dosed to INRs between 2.0 and 3.0
E. Dipyridamole 200 mg and aspirin 25 mg The answer is B.
EXPLANATION: This patient is exhibiting all of the characteristics associated with avoidant personality disorder. Antisocial personality is characterized by selfishness, callousness, promiscuous and impulsive behavior, and an inability to learn from experience and legal problems. Clinical findings of histrionic personality disorder include being dependent, immature, seductive, egocentric, vain, and emotionally labile. Narcissistic personality disorder presents with the clinical findings of grandiosity, a preoccupation with power, lacking interest in others, and excessive demands for attention. Schizotypal disorder is characterized by being superstitious, socially isolated, and suspicious, and having limited interpersonal ability, odd speech and eccentric behaviors. A 55-year-old man with a history of chronic renal failure, 6 months status post renal transplant, presents with chest pain, productive cough, and low-grade fever. He reports generalized malaise as well. Current medications include only those related to the transplant. He has no known allergies. Examination reveals a temperature of 102°F, unremarkable HEENT (head, ears, eyes, nose, throat), and few crackles anteriorly in the upper right lung field. Chest X-ray reveals a solitary nodule in the right upper lobe. The most likely etiology for his symptoms is
A. Streptococcus pneumoniae
B. Pneumocystis jiroveci
C. cryptococcosis
D. Candida The answer is D.
The correct choice is D, thyroid nodule fine needle aspiration. With the advent of fine needle aspiration, it has become much easier, safer, and more reliable to obtain a specimen for biopsy. This patient has several characteristics that increase his risk of malignancy including his gender, young age, firmness of the nodule, and related lymphadenopathy. These, along with the ease of biopsy, suggest this path for diagnostic work up. Not enough information is known to warrant an emergent thyroidectomy, choice E. Choice A, MRI of the anterior pituitary, would be warranted if there was a suspicion of a pituitary cause of the thyroid nodules. Since the TSH is normal and the patient is not presenting with headaches or other pituitary related symptoms, this is not suggested. Choice B, CT of the thyroid, and choice C, MRI of the thyroid, would not provide any additional information after the thyroid scan. They may be helpful prior to any surgery if needed. An elderly women presents with a history of atrial fibrillation and falls. Her current review of symptoms reveals increased sweating and weight loss. A physical exam revealed multiple non-tender nodules on thyroid exam. Which of the following serum lab values is most consistent with this diagnosis?
A. High TSH, high free T3,normal total T4
B. Normal TSH, low free T3, low total T4
C. Normal TSH, high free T3, high total T4
D. Low TSH, high free T3, high total T4
E. Low TSH, high free T3, low total T4 The answer is D.
The correct choice is D, low TSH, high free T3, and high total T4. A diagnosis of toxic multinodular goiter must be made first. This disorder presents with symptoms of hyperthyroidism. In the elderly, patients present more frequently with symptoms of the complications of the disease including cardiovascular and cerebrovascular presentations. These may include atrial fibrillation, congestive heart failure, angina, apathy, and confusion. Other general symptoms of hypermetabolism may include weight loss, sweating, and tremor. Laboratory findings in various causes of hyperthyroidism include a reduced serum TSH, as the pituitary is responding to the increased serum levels of thyroid hormone in the circulation. These thyroid hormone levels feed back on the anterior pituitary, causing a suppression of TSH secretion. In choice A, high TSH, high free T3,and normal total T4, high TSH is only seen in secondary causes of hyperthyroidism (e.g. anterior pituitary origin). This patient's history of multiple thyroid nodules indicates a thyroid cause for her symptoms. In choices B and C, the TSH is normal. This is seen in euthyroid patients. Choice E does include suppression of TSH, but the total T4 is typically elevated in hyperthyroid states. The answer is A.
EXPLANATION: In a patient with these signs, symptoms, and lab findings, acute pericarditis is the most likely diagnosis. In patients with acute pericarditis, EKG changes occur secondary to inflammation of the subepicardium, leading to widespread elevation of the ST segments, often with upward concavity, which returns to normal after several days, followed by T wave inversion. No significant QRS complex changes are noted, so choice C, the development of inferior Q waves (frequently associated with an inferior myocardial infarction), is incorrect. Choice B is frequently noted with severe hyperkalemia. Loss of R-wave amplitude, choice D, is associated with myocardial infarction. Choice E, U waves, are associated with hypokalemia. The answer is E.
EXPLANATION: Choice E, beriberi, also known as thiamine deficiency, is common among alcoholics, and the only high-output cause of congestive heart failure among the choices offered. Other causes include severe anemia, thyrotoxicosis, and arteriovenouis shunting (for example, in hemodialysis patients). Choice A, mitral regurgitation, is a cause of excessive preload, leading to heart failure. Choice D, ruptured chordate tendinae associated with mitral regurgitation, would also be a cause of excessive preload, leading to heart failure. Choices B and C, aortic stenosis and uncontrolled hypertension, are causes in which too much afterload leads to heart failure. ( A 43-year-old male farmer is seen in the oncology clinic for his next round of chemotherapy for acute myelogenous leukemia. He complains of a persistent cough over the last three weeks, but has not run a fever at home. Today, his temperature is 37.4°C, HR is 67, RR is 18, and BP is 120/72. Lung examination is clear to auscultation bilaterally, no lymphadenopathy is noted, color is pale, there is good capillary refill, and the rest of the examination is negative. A CT is obtained, and a RUL wedge-shaped infiltrate at the periphery and a 1 cm cavitary lesion is noted. The best course of treatment would include which of the following?
A. Acyclovir
B. Gentamicin
C. Cefepime
D. Valacyclovir
E. Voriconazole A 48-year-old male presents with an 8-day history of productive cough, subjective fevers, and malaise. He is otherwise healthy without any active medical problems. He is a social drinker of alcohol, and denies any tobacco or drug use. On physical examination, the patient is alert and oriented. His temperature is 100.40F, pulse rate is 56, respiratory rate is 18, and blood pressure is 133/64. HEENT is within normal limits and a chest exam has diffuse expiratory wheeze with decreased sounds to the right lower lung fields. Blood labs reveal WBC 14.4, Hgb 11.3, Plt 233, ALT 65, AST 102, and PO4 2.1. A chest x-ray reveals a dense consolidation with bulging fissures. Based on these findings, what is the most likely pathogen affecting this patient?
A. Klebsiella pneumoniae
B. Legionella pneumophila
C. Pseudomonas aeurginosa
D. Mycoplasma pneumoniae The answer is B.
EXPLANATION: This condition is consistent with urticarial pigmentosa, and it will resolve over time. However, certain things such as NSAIDS, codeine, and scopolamine, as well as extreme temperatures, can cause such reactions as anaphylaxis. This condition is frequently mistaken for child abuse, as the lesions can look like small finger sized bruises. It is consistent, however, with urticaria pigmentosa, which is an accumulation of mast cells in the skin, as indicated by urtication of the lesion after gentle stroking. Urticaria pigmentosa will resolve; however, it will take longer than a week to resolve. Ketoconazole cream is an antifungal that is used to treat fungal infections. The answer is B.
EXPLANATION: Choice B, exercise nuclear stress testing, would provide information regarding exercise tolerance and exercise-induced dysrhythmias, as well as information regarding myocardial ischemia. Choice A, cardiac catheterization, would be utilized in patients diagnosed with acute myocardial infarction or after a stress test suspicious for myocardial ischemia. Choice C, Holter monitor, is a useful diagnostic tool for the evaluation of patients with palpitations occurring on a daily basis. Choice D, tilt table testing, is utilized in evaluation of patients suffering from near-syncope or syncope. Choice E, transesophageal echocardiogram, is helpful in more direct visualization of heart valves, especially when transthoracic echocardiogram is unclear The answer is D.
EXPLANATION: This patient is demonstrating signs and symptoms of right heart failure, and with a history of pulmonary hypertension and a high-pitched diastolic blowing murmur (Graham Steell murmur), Choice D is the most likely of the choices offered. A blowing holosystolic murmur at the left lower sternal border is characteristic for tricuspid regurgitation, Choice A. Choice B, aortic stenosis, presents with a systolic ejection murmur. An atrial septal defect, Choice C, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur that is heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice E, mitral stenosis, presents with a diastolic murmur heard best in the left lateral decubitus position, with the bell of the stethoscope at the apex. A 66-year-old male with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents by emergency medical services (EMS) to the emergency department complaining of severe chest pain with radiation into his back. The patient states that he was feeling well in the morning, but while performing some light activity he felt a "ripping" sensation in his back, which he initially thought was a pulled muscle. The pain continued and the patient started to have chest pain, shortness of breath, and lightheadedness. On initial examination the patient is still in pain, pale, diaphoretic, and has a blood pressure of 85/40. His chest is clear to auscultation, and he has a 3/6 diastolic murmur best appreciated at the base of the heart. Given this clinical scenario, what is the most likely diagnosis?
A. Pneumothorax
B. Dissecting thoracic aneurysm
C. Acute myocardial infarction The answer is C.
EXPLANATION: Choice C, stable angina pectoris, is chest or arm discomfort that is reliably precipitated by activity and/or emotional distress, and relieved with rest or sublingual nitroglycerin. Choice A, pericarditis, would present with chest discomfort that is worse while supine and improves while sitting up, as well as a pericardial friction rub. Choice B, acute myocardial infarction, requires troponin elevation to establish the diagnosis. Choice D, prinzmetal angina, or variant angina pectoris, is defined as coronary artery spasm associated with ST-segment elevation, usually occurring at rest, and frequently at the same time of the day. Choice E, myocarditis, is usually preceded by a viral prodrome. The answer is A.
EXPLANATION: Alzheimer's dementia is a chronic, progressive, neurodegenerative disorder. Acetylcholinesterase inhibitors have been associated with a modest decrease of cognitive decline and increased functioning. These medications increase the levels of acetylcholine, a neurotransmitter, and increase cholinergic activity within the affected brain regions. They have been approved for use in mild to moderate Alzheimer's disease. Memantine, an N-methyl-D-aspartate receptor antagonist, is indicated for use in moderate to severe disease, has been associated with decreased destruction of cholinergic neurons, and may slow cognitive decline. It is often added to acetylcholinesterase inhibitor therapy for progressed disease, but may be first line in a patient unable to tolerate the acetylcholinesterase inhibitor medications. Decarboxylase inhibitor medications inhibit the metabolism of dopamine; one example, carbidopa, is used in conjunction with L-dopa in the treatment of Parkinson's disease. Dopamine receptor agonists activate dopamine receptors in the absence of dopamine, and are useful in conditions with low dopamine levels, such as Parkinson's, prolactinomas, and restless leg syndrome. Selegiline, a monoamine oxidase inhibitor, is selective for monoamine oxidase-B and inhibits catabolic dopamine breakdown, with a potential neuroprotective effect. Use in moderately advanced Alzheimer's disease may slow progression, but remains controversial. The answer is A.
EXPLANATION: Choice A, transthoracic echocardiogram, is the most appropriate next diagnostic study in this patient with atrial flutter, as it can demonstrate the presence of valvular heart disease. The presence of valvular heart disease can change the recommendations for embolism prophylaxis. Atrial flutter is treated similarly to atrial fibrillation in terms of embolism prophylaxis. Choice B, cardiac catheterization, is useful in patients suspected to have unstable angina, or who have sustained a myocardial infarction. Choice C, nuclear stress test, is useful in patients suspected to have angina pectoris, and may be a useful diagnostic study in this patient with cardiac risk factors once the issue of atrial fibrillation has been treated. Choices D and E would be useful tests if the EKG had not established a diagnosis for this patient, with the Holter monitor indicated in patients experiencing symptoms on a daily basis, and the event recorder indicated in patients demonstrating more sporadic symptoms. The answer is A.
EXPLANATION: Patients with pulmonary hypertension and right heart failure frequently demonstrate right ventricular hypertrophy, which leads to tricuspid regurgitation; therefore, choice A is the most likely of the choices offered. This patient is demonstrating signs and symptoms of right heart failure, and with a prior inferior infarction is at risk for the development of tricuspid regurgitation. In addition, the patient demonstrates the blowing holosystolic murmur at the left lower sternal border, which is characteristic for tricuspid regurgitation. Choice B, aortic stenosis, presents with a systolic ejection murmur. An atrial septal defect, choice C, if large, could present with similar symptoms of exertional dyspnea secondary to a large shunt, but auscultation would reveal a moderately loud systolic ejection murmur heard best in the second and third interspaces. This is secondary to increased pulmonary arterial flow. Choice D, aortic regurgitation, presents with a soft diastolic murmur heard best at the left sternal border The correct choice is B, suggest preparing a food diary to look for patterns and choices. According to the NCEP ATP III guidelines, this patient does not have any risk factors for coronary heart disease. Her LDL level should be less than 160 mg/dL. All patients can benefit from observing their dietary habits and looking for opportunities to make changes to lower their fat intake. Dietary cholesterol should be less than 200 mg/day, and soluble fiber should be included in the diet. Patients can look at their eating patterns at home, look at the methods used for cooking and baking, and determine the frequency of eating out. Strict changes in her diet, choice A, are not necessary at this time. She already exercises regularly and her HDL is at an adequate level. Therefore, choice C, increasing the amount of exercise to five days per week, is not necessary. Choice D, start a lipid lowering agent such as niacin, is not recommended. Niacin is used to increase serum HDL and lower serum LDL. Her lipid levels are within the reference ranges. Choice E, suggest starting a low carbohydrate diet, may be associated with short-term weight loss, an increase in HDL, and a decrease in triglycerides. This is not something that this patient requires. The answer is D.
EXPLANATION: BPPV is characterized by sudden vertigo, made worse with head position change, and accompanied by nausea and vomiting. Meniere syndrome is characterized by episodic severe vertigo, fluctuating sensorineural hearing loss, tinnitus, and ear "fullness." Pathologically, there is distention of the endolymphatic system throughout the inner ear, presumably due to dysfunction of the endolymphatic sac. Labyrinthitis is characterized by severe vertigo and hearing loss, and is likely a result of a viral inner ear infection. Vestibular neuronitis is also a result of a viral inner ear infection, with symptoms of severe vertigo, nausea, and vomiting, without hearing loss. Both labyrinthitis and vestibular neuronitis resolve in one to two weeks. Presbycusis is age related hearing loss. The answer is E.
EXPLANATION: Within the motor region of the cerebral cortex and brain stem, motor neurons originate and extend to the spinal cord, allowing nerve signals to transmit to lower motor neurons. These neurons travel in multiple pathways, also known as tracts, allowing for various voluntary muscle functions. Lesions within the upper motor neuron pathways will impact these muscle functions as a result of interrupted nerve transmission. Signs may include increased antigravity muscle tone, with a characteristic abrupt catch response, followed by an increase then decrease of resistance to passive movement, which is termed the "clasp knife" phenomenon. Muscles involved with relaxing the antigravity musculature are weakened. Hyperreflexia and spasticity are also common. Clonus, rhythmic involuntary muscle contractions following an abruptly applied stretch, may also be present. The Babinski sign, extension of the large toe with extension of the other toes simultaneously when the lateral plantar surface of the foot is stimulated, is a sensitive indicator of an upper motor neuron lesion. The other areas have classic signs and symptoms, based upon the functions they control. The answer is A.
EXPLANATION: In symptomatic patients demonstrating significant mitral valve stenosis, mitral valve replacement after cardiac catheterization,is recommended, to evaluate for associated valvular disease and coronary artery disease. This allows planning for possible concomitant coronary artery bypass surgery, with mitral valve replacement and or other valve replacement, if necessary. As the patient is symptomatic and demonstrates both severe mitral stenosis and mitral regurgitation, choice A is the most appropriate next step in management. Choices B and C are thus inappropriate, as the patient is already symptomatic. If the patient were not symptomatic, choice B would be a more viable choice compared to choice C, because it is less invasive than transesophageal echocardiogram. Choice D would be inappropriate, as strenuous physical activity should be avoided in patients with severe mitral valve stenosis. Choice E is appropriate therapy for patients at risk for ventricular tachycardia/fibrillatio The answer is B.
EXPLANATION: Asthma, in this case exercise-induced, is the most likely cause of this problem. The symptoms commonly associated with acute exacerbations of asthma include wheezing, cough, dyspnea, and chest pain. Some symptoms that might be suggestive of asthma include exercise-induced cough, nighttime cough, cough after cold air exposure, and cough after laughing. Airway foreign bodies, though not common, are an acute problem that may present as sudden cough, choking, and wheezing. A 66-year-old man with a history of HTN and diabetes mellitus, type 2, presents to the emergency department with complaints of palpitations for over 2 weeks, tachypnea, and chest pain. He denies history of CAD, stroke, TIA, or congestive heart failure. He is afebrile, with vital signs as follows: BP 145/98, HR 138, and RR 22. His EKG is shown (Figure 1). Troponins are negative X 3. Which of the following choices is the most appropriate next diagnostic study for this patient?
A. Transthoracic echocardiogram
B. Cardiac catheterization
C. Nuclear stress test
D. Holter monitor
E. Event recorder The answer is A.
EXPLANATION: Choice A, transthoracic echocardiogram, is correct, as it can demonstrate the presence of valvular heart disease. The presence of valvular heart disease can change the recommendations for embolism prophylaxis. Choice B, cardiac catheterization, is useful in patients suspected to have unstable angina, or who have sustained a myocardial infarction. Choice C, nuclear stress test, is useful in patients suspected to have angina pectoris, and may be a useful diagnostic study in this patient with cardiac risk factors (once the issue of atrial fibrillation has been treated). Choices D and E would be useful tests if the EKG had not established a diagnosis for this patient, with the Holter monitor indicated in patients experiencing symptoms on a daily basis, and the event recorder indicated in patients demonstrating more sporadic symptoms. 