USMLE Forums banner
1 - 20 of 22 Posts

·
Registered
Joined
·
27 Posts
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 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
 

·
Registered
Joined
·
27 Posts
Discussion Starter · #3 ·
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?
 

·
Registered
Joined
·
309 Posts
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. :).
 

·
Registered
Joined
·
177 Posts
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
 

·
Registered
Joined
·
1 Posts
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.
 

·
Registered
Joined
·
454 Posts
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
 

·
Registered
Joined
·
36 Posts
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.
 

·
Registered
Joined
·
83 Posts
i guess echo will be the best thing to do, it is the only test which is going to make difference in the management.
 

·
Registered
Joined
·
168 Posts
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.
 

·
Registered
Joined
·
31 Posts
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.
 

·
Registered
Joined
·
98 Posts
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.
 

·
Registered
Joined
·
59 Posts
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!!
 

·
Registered
Joined
·
10 Posts
..

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?
 
1 - 20 of 22 Posts
Top