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Discussion Starter · #1 ·
An 81-year-old man is hospitalized for acute onset of shortness of breath and lower extremity edema. Although he lives by himself, it is very difficult for him to move around his apartment without experiencing fatigue. He has not seen his physician in years but was told in the past that he had high blood pressure. On physical examination, his jugular venous pulse is seen 9 cm above his sternal notch, inspiratory crackles are heard at his lung bases, and there is 3+ lower extremity edema. Which of the following is most likely to confirm the diagnosis?
(A) Cardiac angiography
(B) Echocardiography
(C) Electrocardiogram
(D) Endomyocardial biopsy
(E) Pulmonary function tests
(F) X-ray of the chest
 

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The diagnosis is undoubtedly CHF and the intuitive answer is echocardiography for the diagnosis.

However, I have the impression that the Framingham study (which has been adopted by AHA) implicates chest x-ray as a major diagnostic criterion and the findings of cardiothoracic index >.5 and pulmonary edema (i.e. interstitial fluid collection, Kerley B lines, inversion of pulmonary blood flow to upper pulmonary fields) as determinants of the diagnosis of CHF. And this is understandable, to the point that echocardiography demands an experienced physician to assess parameters such as ejection fraction, hypokinesia of the ventricular walls etc, while reading an x-ray is a duty that a medical student is able to bring off (at least, should be...).

Would you like to comment, please?
 

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Discussion Starter · #5 ·
Yes, It's Echo

The correct answer is B. The patient most likely has an acute congestive heart failure exacerbation with the underlying etiology being hypertension. Echocardiography is an essential test in all patients with newly diagnosed heart failure and is an excellent, noninvasive method of assessing chamber size, function, and ejection fraction.

Answer A is incorrect. Cardiac angiography can determine cardiac pressures, but given the invasive nature of the procedure, it is best reserved for congestive heart failure patients in whom coronary artery disease is suspected as the underlying cause.
Answer C is incorrect. ECG in heart failure may show left ventricular hypertrophy in this patient, but is unlikely to be helpful if acute ischemia
is not suspected.
Answer D is incorrect. Biopsy does play a role in the evaluation of heart failure, but is generally reserved for cases of unknown origin or acute cases in young patients. Certain causes of heart failure such as infiltrative disease can be confirmed by biopsy, but it is not likely to be useful here.
Answer E is incorrect. Pulmonary function tests have a role in the evaluation of dyspnea. However, they are not necessary if a cardiac
cause is strongly suspected.
Answer F is incorrect. X-ray of the chest in heart failure may show pulmonary congestion or cardiomegaly, but these findings are relatively
nonspecific.
 

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Discussion Starter · #6 ·
Re: Cxr

... chest x-ray as a major diagnostic criterion and the findings of cardiothoracic index >.5 and pulmonary edema (i.e. interstitial fluid collection, Kerley B lines, inversion of pulmonary blood flow to upper pulmonary fields) as determinants of the diagnosis of CHF. And this is understandable, to the point that echocardiography demands an experienced physician to assess parameters such as ejection fraction, hypokinesia of the ventricular walls etc, while reading an x-ray is a duty that a medical student is able to bring off (at least, should be...).

Would you like to comment, please?
The question is asking how to confirm the diagnosis.
 
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