During his physical examination, a 45-year-old man with a history of smoking states that he gets short of breath when he works hard physically. On examination, the only positive finding was jugular venous distension (JVD) of approximately 6 cm, which increased to 8-9 cm when pressure was applied to his liver or when he was short of breath. An echocardiogram, ECG, abdominal ultrasound, and liver function tests are all unremarkable. Would a stress test be appropriate?
—Khalid Butt, MD, Bainbridge, N.Y.

This patient certainly has significant risk for CAD, and his shortness of breath may be an anginal equivalent. I think it would be very appropriate to perform an exercise stress test; a cardiopulmonary stress test would be very useful as well. Stress testing would enable you to observe his exercise capacity and exertional symptoms and may help determine if those symptoms are secondary to coronary insufficiency or respiratory in nature. I would also order pulmonary function testing, as his symptoms and JVD may be due to pulmonary disease, given his smoking history.
—Norma M. Keller, MD (113-19)

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