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Old 10-20-2011
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Heart Decompensated Heart Failure

A 70-year-old man is hospitalized after 2 days of increasing shortness of breath with exercise. He also notes increased dyspnea at rest. He complains of increased peripheral edema and a 25-lb weight gain over the past 2 weeks. He sustained a massive myocardial infarction 2 years ago, at which point his echocardiogram revealed an ejection fraction of 25% with left ventricular dysfunction and dilation. His stress test performed 6 months before admission was negative for active ischemia. His medications include lisinopril 10 mg daily, furosemide 20 mg daily, warfarin 5 mg daily, and digoxin 0.125 mg daily. On admission, the patient is administered 40 mg of intravenous furosemide and he undergoes brisk diuresis. Two days later his blood pressure and heart rate are normal. His jugular venous pressure is 14 cm of water. Lungs are clear to auscultation. Cardiac examination is notable for an S3 and S4. An electrocardiogram shows a stable left bundle branch block. Which of the following would be suitable for diagnostic purposes in this patient?
A. Chest radiograph
B. Echocardiogram
C. High-resolution CT scan of the chest
D. Pulmonary artery catheter placement
E. Ventilation-perfusion scan
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Old 10-20-2011
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B. Echocardiogram??
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Old 10-21-2011
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C. High-resolution CT scan of the chest
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D. Pulmonary artery catheter placement
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Default Answer

The correct answer is B. This patient is presenting with decompensated heart failure. His bilateral leg edema, jugular venous distention, and pulmonary edema support this diagnosis. In addition to monitoring his electrolytes, the next step would be to repeat an echocardiogram to better assess his left ventricular function.

Typically, a chest radiograph would be obtained in the emergency room (choice A). However, if resources were limited an echocardiogram would provide the maximum amount of information. Pulmonary infection would be on the differential diagnosis in this patient as well. Thus, if the patient were not improving after diuresis, an infection would need to be ruled out.

Pulmonary embolus is low on the differential diagnosis, and there is little reason to suspect interstitial lung disease in this patient. Thus a high-resolution CT scan of the chest (choice C) would not add much to the diagnosis.

Pulmonary artery catheters (choice D) are very helpful in making the diagnosis of heart failure if the diagnosis is not clear. Further, this has the advantage of assisting in effective management of heart failure. However, this invasive diagnostic and therapeutic maneuver is not needed at this time.

A ventilation-perfusion scan (choice E) would assist in making the diagnosis of a pulmonary embolism. However, the diagnosis is not very high on the differential.
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