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  #1  
Old 10-14-2013
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Heart How to diagnose this cardiac patient

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 136/88 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 S3 gallop. There is 2+ edema ofthe lower extremities. Pulse oximetry shows an oxygen saturation of 90%. Which of the following is the most appropriate next step in diagnosis?
A) x-ray film of the chest
B) Ambulatory ECG monitoring
C) Thallium stress test
D) Echocardiography
E) Ventilation-perfusion lung scans
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  #2  
Old 10-14-2013
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I'd go with Echo
Anyone else?
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  #3  
Old 10-14-2013
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Default i would go for echo too

this question in from NBME 3 form
the offline answer is chest x-ray BUT I agree with you that it should be echo

the patient has signs and symp of pulmonary edema and hx of cardiac disease
and echo is the most important diagnostic test to tailor the management upon because it will differentiate systolic from diastolic dysfunction according to the EF

what do you think people?
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  #4  
Old 10-14-2013
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what's offline answer?
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  #5  
Old 10-14-2013
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Quote:
Originally Posted by AiLSP View Post
what's offline answer?
not official answers
answers by others
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  #6  
Old 10-14-2013
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Next time, in the title.... please state that it's a NBME question for the people who haven't done the Forms and will be using it as an assessment tool later on down the road. .
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  #7  
Old 10-14-2013
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I think its chest X ray.

Think that, In a hospital a patient with Biventricual failure and Pulmonary edema , a doctor will first do the chest X ray , not ECHO. They ask what is the next best step
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  #8  
Old 10-15-2013
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mtb says best initial test is tte...
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  #9  
Old 11-04-2013
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I think I had this question before and the answer was a VQ scan. There is dullness over the right lung base and decreased sounds. You already know he's in CHF, most likely RHF due to the increased JVP and peripheral edema. In acute failure, an echo isn't going to offer much because you are going to diurese this guy like crazy. A CXR is just going to show you that he's full of fluid- again, same treatment. So i'd rule out a PE first.
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  #10  
Old 11-04-2013
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Quote:
Originally Posted by leanni View Post
I think I had this question before and the answer was a VQ scan. There is dullness over the right lung base and decreased sounds. You already know he's in CHF, most likely RHF due to the increased JVP and peripheral edema. In acute failure, an echo isn't going to offer much because you are going to diurese this guy like crazy. A CXR is just going to show you that he's full of fluid- again, same treatment. So i'd rule out a PE first.
Even if you suspect PE the next appropriate test is a chest x ray then vp scan/spiral ct / ctpa
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  #11  
Old 11-05-2013
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Default cardiac qtn

most common finding in a cxr of a suspected PE is normal CXR, but in this pt i wud first rule out Pleural effusion and cardiomegaly by CXR.
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  #12  
Old 11-12-2013
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i guess echo will be the best thing to do, it is the only test which is going to make difference in the management.
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  #13  
Old 11-13-2013
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For all cases, don't forget that the most important thing is the PRESENTING COMPLAINT. Even if it really really looks like this patient is in heart failure, it is still just a part of the long list of differential diagnosis for shortness of breath.

Therefore, you are not actually trying to confirm this patient has CHF, you are actually investigating for why he is short of breath. Therefore, the right answer is to do a Chest X-Ray.

If you see signs of Pulmonary Edema, than the next step would be to do an echo.
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  #14  
Old 11-15-2013
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I think its chest X ray.
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  #15  
Old 11-18-2013
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Quote:
Originally Posted by Lawliet View Post
For all cases, don't forget that the most important thing is the PRESENTING COMPLAINT. Even if it really really looks like this patient is in heart failure, it is still just a part of the long list of differential diagnosis for shortness of breath.

Therefore, you are not actually trying to confirm this patient has CHF, you are actually investigating for why he is short of breath. Therefore, the right answer is to do a Chest X-Ray.

If you see signs of Pulmonary Edema, than the next step would be to do an echo.
I agree with you on this one.
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  #16  
Old 11-22-2013
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I cannot see the rationale for PE here! He's been having this complaint for the past two weeks... it's not sudden onset dysnea or anything to suggest PE. This is most likely CHF and you have to assess for pleural effusion, and CXR is best here. Echo comes next, to check for Ejection Fraction. In any case, it's very common for a CHF patient to have CXR done and be managed accordingly.
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  #17  
Old 12-02-2013
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Default pls put a spoiler alert

why cant people put a spoiler alert before posting nbme question?
it just spoils other peoples preparation. just not good!!
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  #18  
Old 10-03-2014
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yeah I'd do an EKG first, then an X-ray, then Echocardiography (assuming that the previous tests would confirm HF)
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  #19  
Old 10-04-2014
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Default ..

I think is CXR, although I do not see how the management of this patient would differ with an Xray. He is clinically in heart failure and therapy should be started promptly. ECO sounds good for me because it documents which type and severity of the HF. Why the patient is not anticoagulated?
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  #20  
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I think it's mostly about excluding other possible causes, and it's such a quick and easy test
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  #21  
Old 06-25-2015
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Start with the easy one CXR then echo , personal opinion
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  #22  
Old 06-28-2015
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I believe the answer is Chest X ray as it is the only modality which will change the management of the patient. If the chest x ray would show signs of Pulmonary Edema, it would be an indication to start patient on Loop Diuretics like furosemide. Also, his oxygen sat is low (90%) which might hint towards a pulmonary pathology.

All the other options have no impact on immediate management of the patient. Although echo and thallium scan seems like a good options, they have no role in immediate management of the patient.

EKG would be a good idea if the presenting complaint was chest pain.
For those people suspecting Pulmonary Embolism, this patient has S.O.B for 2 weeks. PE presents with sudden onset of S.O.B
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