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Old 12-16-2012
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Arrow A 55-year-old man left heart failure

A 55-year-old man presents to his physician’s office with increasing dyspnea on exertion. He denies chest pain, diaphoresis, nausea, or vomiting. He has been involved in eight motor vehicle accidents in the past 3 years. Past medical history is significant for hypertension, for which he takes a diuretic. His temperature is 37.2 °C (99.0°F), blood pressure is 121/82 mm Hg, pulse is 85/min, respiratory rate is 14/min, and oxygen saturation is 99% on room air. Physical examination is significant for diffuse and laterally displaced point of maximal intensity and an S3 gallop. Which of the following is the most appropriate next step in diagnosis?

(A) Cardiac catheterization
(B) Echocardiogram
(C) Exercise tolerance test
(D) Polysomnography
(E) X-ray of the chest
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Default ECG

B...to caclculate EF
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Why not E first then B?
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I think most appropriate next step should be E)
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Quote:
Originally Posted by stepdoc1 View Post
Why not E first then B?
I don't think CXR is needed since they have told us the apex is maximally displaced laterally with S3 so I go for "B"
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Here question has asked for next step but not the best step in that case the answer would be B) Echocardiography.
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I would go with Echo. I don't see that Xray is necessary here, since it's clearly heart failure.
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i think ECHO.....since doing chest x ray next will not help in diagnosis....
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i go with E .as s3 and dyspnea and long term HT leads to increase LV size.
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(E) X-ray of the chest


Most appropriate next step>>>>>Take away his Driver's license.
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Quote:
Originally Posted by Novobiocin View Post
(E) X-ray of the chest


Most appropriate next step>>>>>Take away his Driver's license.
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Surprisingly the correct answer is D.
Bank explanation.
The patient’s history and physical examination are highly suspicious for sleep apnea (((No any clue for that))) . Obstructive sleep apnea (OSA) is most prevalent in men ages 30–60 years, who present with a history of snoring, excessive daytime sleepiness, nocturnal choking or gasping, witnessed apneic episodes, moderate obesity (Not mentioned in the Q), and hypertension. The patient’s dyspnea on exertion, diffuse and laterally displaced point of maximal intensity, and S3 gallop are all signs and symptoms of left heart failure, a manifestation of OSA. It is believed that left heart failure arises from repetitive episodes of nocturnal asphyxia and concomitant negative intrathoracic pressure. The negative intrathoracic pressure increases cardiac afterload, which manifests over time as left heart failure. The definitive diagnostic modality for OSA is a sleep study (polysomnography). Polysomnography documents arousals, obstructions, episodes of hypoxemia, and the various stages of sleep. A sleep study would be useful in this case because it would confirm the diagnosis and establish the need for therapeutic intervention with continuous positive airway pressure.
Any suggestions....
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I think the question writer managed to confuse himself here.

I agree that " involved in eight motor vehicle accidents in the past 3 years" (because he keep falling asleep behind the wheel) does points to OSA BUT this patient has heart failure and the next step is unequivocally a CxR. No one will even dare to ask for a Polysomnography without doing a CxR in a patient with clear signs of heart failure.
However, if the question asked "What is the best step in management" then the answer would have been Polysomnography.
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Quote:
Originally Posted by heartbeat View Post
Surprisingly the correct answer is D.
Bank explanation.
The patient’s history and physical examination are highly suspicious for sleep apnea (((No any clue for that))) . Obstructive sleep apnea (OSA) is most prevalent in men ages 30–60 years, who present with a history of snoring, excessive daytime sleepiness, nocturnal choking or gasping, witnessed apneic episodes, moderate obesity (Not mentioned in the Q), and hypertension. The patient’s dyspnea on exertion, diffuse and laterally displaced point of maximal intensity, and S3 gallop are all signs and symptoms of left heart failure, a manifestation of OSA. It is believed that left heart failure arises from repetitive episodes of nocturnal asphyxia and concomitant negative intrathoracic pressure. The negative intrathoracic pressure increases cardiac afterload, which manifests over time as left heart failure. The definitive diagnostic modality for OSA is a sleep study (polysomnography). Polysomnography documents arousals, obstructions, episodes of hypoxemia, and the various stages of sleep. A sleep study would be useful in this case because it would confirm the diagnosis and establish the need for therapeutic intervention with continuous positive airway pressure.
Any suggestions....
Where is this question from?
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