The Correct Answer is C!

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A 35-year-old man is seen in the office for follow-up examination. Two days ago, he was seen in the emergency department with sudden onset of chest pressure, shortness of breath, palpitations, mild lightheadedness, and tingling on the tips of both hands and around his mouth while sitting at his desk at work. He reports having had symptoms three times over the past 1 month, including once during a work meeting and another while watching television at home. His first episode prompted an emergency room visit, which resulted in a negative workup including normal ECG and cardiac enzymes. His symptoms were attributed to “stress and anxiety,” and he was discharged.

The patient still worries that this is related to his heart and has even stopped working out at the gym where he normally runs 3 to 5 miles on the treadmill; although, he has never had the symptoms while exercising. He has started to become more anxious about leaving home except to go to work because he is afraid of having an episode in public. He says that the episodes seem to occur randomly and are never correlated with a sense of stress or anxiety preceding them. Besides these recent episodes, the patient denies anxiety, unusual stress, change in his mood, or feelings of loss of interest.

He denies other medical problems and does not take any prescription medications or supplements. He denies use of tobacco, excessive caffeine, or illicit drugs; he drinks alcohol occasionally (typically 2 drinks or less each week). His family history is significant for his father who suffered a myocardial infarction at the age of 70. On physical examination, the patient is alert and oriented. The heart rate is 90/min, and blood pressure is 125/72 mmHg. His affect is appropriate and speech is normal. His cardiovascular and lung exams are also unremarkable.

Laboratory findings from his recent emergency room visit include normal serum electrolytes, complete blood count, and cardiac enzymes. A urine drug screen was also negative. An ECG showed normal sinus rhythm and no acute ischemic changes.


Which of the following is the most appropriate next step in the management of this patient?

  1. Check serum thyroid-stimulating hormone
  2. Check serum metanephrine level
  3. Prescribe paroxetine
  4. Order treadmill exercise stress test

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