doyoudig
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19. 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?
O A) X-ray film of the chest
O B) Ambulatory ECG monitoring
O C) Thallium stress test
O D) Echocardiography
O E) Ventilation-perfusion lung scans
Ddddddd
Why not X ray as the next step? If you were working in the ED would you not order and X ray first then go the echo?
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| tamerbashir
Forum Elite
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best initial yes x ray
then echo
or may be coz it is clinically daignosed already as ischemic cardiomyopathy need to measure ejection fraction now ????
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| Gourdon
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is D your first choice or you have found it as the right ans somewhere?
I am looking for the whole right answers of the NBME Qs, Do you know any source?
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| chemamr
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CXR first. Even if the answer given is D, that does not mean that is the most correct thing to do in real life.
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| Vietnamese
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D- Echocardiograhy will give rise to many parameter in diagnosis in this case. It is very helpful to adjust medication in time, especially Ejection Fraction, thrombosis in left atrium of fillbrilation and so on. CXR can not make different likewise. On clinical and history settings, CHF is pretty clear and CXR not add more usefully than Echo.
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| dr19
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CXR...to distinguish cardiogenic pulmonary edema from other causes of severe dyspnea
Echocardio....to determine LV function,both systolic and diastolic...to determine the presence of valvular heart disease,LV wall sickness,chamber size,pericardial disease and regional wall abnormalities that may suggest ischemic CAD as the cause.
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| alzheimer
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AAAAAAAAAAA
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| chemamr
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again I think the answer should be CXR. I'm not against doing an echo, pt also needs it and can be done after CXR.
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| Korotkoff
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Sure CXR is the next step.
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| fudoc_20
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I AGREE WITH VITNAMESE !?
WHY we would do cxr? what we wanna see ?!! cardiomegaly , pulmonary congestion,... so evident from history and examintaion it is congestive heart faliure !is( there other diff diagnosis ! that the XRAY would help to rule out so that we would go to other step ,other than echo)
so even if we did cxr we will still have do echo after it to detect the severty of heart faliure by ejection ffraction !!
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| farnsworth
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(A): CXR
The patient has congestive heart failure (clinical presentation), but he does not seem to be unstable. So start your treatment (oxygen or better: non-invasive ventilation, iv, furosemide 40mg iv, nitroglycerine 0.8mg sl to reduce pre- and afterload as long as BPsys>100mmHg, morphine titrated to effect for dyspnea). The next step you might do is: draw blood (CBC, chemistry, glucose&HbA1C, CRP/IL-6/Procalcitonin, LFT, cardiac enzymes + ANP, Bun, Cr, you might as well determine digoxin levels), ECG, CXR. After you've done ECG and CXR, the results from the lab will most probably be available.
The CXR will probably show cardiomegaly, pulmonary congestion, and a pulmonary effusion on the right side (decreased breath sounds, dullness to percussion). It should be done to rule out other pathologies.
Nevertheless, an echocardiography has to be done (routine! Not necessarily in the ER). If the echo shows signs of abnormal wall motion -> thallium stress test.
Since the patient is most probably arrhythmic for a long period (digoxin!), ambulatory ECG monitoring does most probably not bring up new information.
Ventilation perfusion scans: I can hardly remember seeing one. Before ordering a V/Q scan, I would order a CTPA (faster, more sensitive).
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| nyimalay
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I agree with A. CXR
It can show the extent of Rt pleural effusion too. Echo is needed but not before CXR.
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| fudoc_20
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well as u said heart faliure is aclinical syndrome which already diagnosed on clinical basis and that is the case here !! SO who say cxr !! would they pls tell me!what they may expect to see according to the history and examination !other than picture of congestive heart faliure !?what other pathologies we wanan see? or we just do cxr to rule out other dieases ! routinely like broncongenic carcinoma although the presntation sugests heart faliure ! wich is better confirmed and assesed by echo!!
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| dr_arc
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first step in this case- CXR to figure out the deceased breath sounds and dullness to percussiion over the right lung base.
Had it not been for this detail in thehistory the inv of shoice would be echo.
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| farnsworth
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If the patient was unstable, the answer would be echo (before CXR). In that case you have to evaluate the volume status, as well as myocardial contractility (systolic/diastolic dysfunction) and valve defects.
This will guide you therapy: inotropes, vasopressors, fluids, or diuretics.
When the patient is stabilized, proceed w/ CXR to rule out pneumonia, check for pleural effusions etc.
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