07-08-2008, 09:24 PM
A 78-year-old man mentions during his annual physical examination that he has had very occasional episodes of angina with mild exertion. The most recent episode was 2 months ago. He has a history of hypertension and mild exertional dyspnea, and his medications include enalapril 5 mg daily, hydrochlorothiazide 25 mg daily, aspirin 81 mg daily, sublingual nitroglycerin, metoprolol 25 mg daily, and lovastatin 80 mg daily. He refused coronary angiography when it was suggested at his physical examination 1 year ago. The patient is otherwise healthy and has not been hospitalized in more than 10 years.
On examination, the blood pressure is 170/94 mm Hg and the heart rate is 62/min. There is no jugular vein distention. There is a faint left carotid bruit. Lungs are clear, and cardiac examination reveals normal S1 and S2, and a 2/6 short systolic ejection murmur. The electrocardiogram shows left ventricular hypertrophy and nonspecific T-wave abnormalities. Laboratory studies, including electrolytes and creatine kinase MB fraction, are normal.
What should be the next treatment?
A Increase metoprolol
B Increase enalapril
C Add nisoldipine
D Add amlodipine
E Increase aspirin
On examination, the blood pressure is 170/94 mm Hg and the heart rate is 62/min. There is no jugular vein distention. There is a faint left carotid bruit. Lungs are clear, and cardiac examination reveals normal S1 and S2, and a 2/6 short systolic ejection murmur. The electrocardiogram shows left ventricular hypertrophy and nonspecific T-wave abnormalities. Laboratory studies, including electrolytes and creatine kinase MB fraction, are normal.
What should be the next treatment?
A Increase metoprolol
B Increase enalapril
C Add nisoldipine
D Add amlodipine
E Increase aspirin