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Discussion Starter · #1 ·
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?

is it ekg or chest xray
 

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The history and PE points very strongly to biventricular filure. I think a CXR is more appropriate than an ECG at this stage. It will reveal the signs of pul congestion and effusion if present(meniscus sign, Kerley B lines, blunting of costo phrenic angles etc) and possibly show an enlarged heart since there's an s3.
An ECG will still be needed, seeing as his heart rate is irregular but not before a CXR.
 

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Discussion Starter · #3 ·
The history and PE points very strongly to biventricular filure. I think a CXR is more appropriate than an ECG at this stage. It will reveal the signs of pul congestion and effusion if present(meniscus sign, Kerley B lines, blunting of costo phrenic angles etc) and possibly show an enlarged heart since there's an s3.
An ECG will still be needed, seeing as his heart rate is irregular but not before a CXR.
Sorry, it was not EKG , its ECHO/ XRAY. The thing is In MTB it says that ECho is the test of choice to diagnose Heart FAILURE. But, chest xay is definitely one of the things we should do, the question is what comes first
 
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