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Old 06-08-2015
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Default Pulmonary/Cardio Question

A 69-year-old retired man is brought to the emergency department
because he experienced sudden onset of left-sided chest
pain, which is exacerbated upon inspiration. He is taking no
medications and has been in good health. Physical examination
reveals dyspnea and hemoptysis. Temperature is 38°C
(101°F), pulse rate is 98 per minute, respirations are 35 per
minute, and blood pressure is 158/100 mm Hg. A pleural friction
rub is present on auscultation. The left leg is markedly
edematous, with a positive Homans’ sign. An ECG shows a
normal sinus rhythm. A chest X-ray reveals a left pleural effusion.
What is the most likely cause of this patient’s pulmonary
(A) Congestive heart failure
(B) Cor pulmonale
(C) Mitral stenosis
(D) Subacute endocarditis
(E) Thromboembolism

The answer is E (and I see it) but can someone explain why A&B are wrong?
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Old 06-08-2015
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With CHF or R sided heart failure, you'll have bil extremity edema due to back up from the heart into the venous system. Here, only one leg is edematous, and that's due to a DVT. A mild PE could show diffuse EKG changes potentially, while CHF or cor pulmonale could show more MI-like EKG changes if cardiogenic in nature. Also, + Homan's is pain in the calf with dorsiflexion while the knee is extend, which increases suspicion for DVT. Cor Pulmonale and CHF are usually slower onset as a result of other heart problems, which this case is acute in nature. If the CHF is due to an MI damaging the heart, for example, you'd have EKG changes showing an old MI and he would probably have a history of MI's on record. This pt has no prior health problems or medications to speak of. And the most common cause of right sided heart failure, is left sided heart failure, so he would have experienced symptoms of left sided heart failure prior to this episode; again, more chronic heart problems vs acute. The pleural effusion is also unilateral, increasing suspicion for a source at the lung itself. CHF would likely result in diffuse pleural effusions.

Last edited by chenn; 06-08-2015 at 10:37 AM.
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