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Old 07-27-2014
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Default nbme 3-one question to ask

Over the past 2 weeks, a 60-year-old man has had shortness of breath on exertion. He also has paroxysmal nocturnal dyspnea with two-pillow orthopnea. He has taken aspirin daily since a myocardial infarction 3 years ago. He has a history of atrial fibrillation well controlled with digoxin and type 2 diabetes mellitus treated with diet. His blood pressure is 136188 mm Hg, pulse is 98/min and irregular, and respirations are 20/min. Jugular-venous pressure is increased. Breath sounds are decreased over the right lung base.. there is dullness to percussion. Cardiac examination shows an S. gallop. There is 2+ edema of the lower extremities. Pulse oximetry shows an oxygen saturation of 90%. Which of the following is the most appropriate next step in diagnosis?
O A) X-ray film of the chest
O B) Ambulatory ECG monitoring
O C) Thallium stress test
O D) Echocardiography
O E) Ventilation-perfusion lung scans

How to choose between A and D? I thought D is more accurate than A since sometimes chest X-ray won't show the cardiomegaly.
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Old 07-27-2014
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They're asking for the "most appropriate next step" ... which would be "A" (in my opinion)... to confirm pulmonary edema or any other cause.
since we can already guess the cause is cardiac in nature by looking at the elevated jugular venous pressure... now, the echo can be used to differentiate between systolic or diastolic nature of the failure. But initial step should be plain radiography to visualize the lung fields.
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Old 08-08-2016
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Does anyone knows the actual answer ?
this q has got me so confused .... at the beginning i thought i was clear but now i just dont know what to think

i feel EKG is the most app. because it looked to me the pt is having a pulmonary edema due to worsening of HF, so according to MTB2 .the most app. step in management is to do an EKG , and according to the ekg then u treat the pt.

"We are what we repeatedly do. Excellence, then, is not an act, but a habit."
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