WBR0996

Author	[[PageAuthor::Mohamed Moubarak, M.D. [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 62 year-old man comes to ED complaining of acute shortness of breath, fatigue, and worsening exertional dyspnea. He hardly can talk, and mentioned waking up several times at night on sever cough with frothy sputum. He used to sleep on two pillows but now he is using three. The patient has past medical history of hypertension for 15 years, and diabetes mellitus for 20 years. On examination, his BP 90/70, pulse 120, respiratory rate 28, and temperature is 36.9 C (98.5F). Chest examination revealed decreased breath sounds and dullness at both bases with bibasilar rales. Cardiac examination revealed diffuse, laterally and inferiorly displaced apex, with distant heart sounds and S3 gallop. There is a jugular venous distention, with JVP of 12 cm, and oxygen saturation of 83%. Extremities are cool and show 2+ pitting edema in both legs up to the knees. Which of the following is the best next step in managing this patient?]]
Answer A	AnswerA::Chest x-ray
Answer A Explanation	[[AnswerAExp::Incorrect While chest x-ray is one of the initial tests to be ordered, acute pulmonary edema is a clinical diagnosis, and starting with a life saving medications has the priority.]]
Answer B	AnswerB::Diltiazem
Answer B Explanation	[[AnswerBExp::Incorrect Diltiazem should be avoided in patients with impaired left ventricular function due to negative inotropic effects.]]
Answer C	AnswerC::Oxygen, furosemide, nitrates, and morphine
Answer C Explanation	[[AnswerCExp::Correct Oxygen, furosemide, nitrates, and morphine are the most important next step to start with.]]
Answer D	AnswerD::Metoprolol
Answer D Explanation	[[AnswerDExp::Incorrect ACE inhibitors and beta-blockers do decrease mortality and morbidity in CHF; however their use in acute decompensated heart failure is suspected as they may induce hypotension and further cardiogenic shock.]]
Answer E	AnswerE::Lisinopril
Answer E Explanation	[[AnswerEExp::Incorrect ACE inhibitors and beta-blockers do decrease mortality and morbidity in CHF; however their use in acute decompensated heart failure is suspected as they may induce hypotension and further cardiogenic shock.]]
Right Answer	RightAnswer::C
Explanation	[[Explanation::Pulmonary edema is a clinical diagnosis. Shortness of breath, rales, S3, and orthopnea are more important in establishing the diagnosis than any single test. In acute cases, Oxygen, furosemide, nitrates, and morphine are the most important next step to start with. Educational Objective: References: ]]
Approved	Approved::No
Keyword	[[WBRKeyword::Pulmonary edema]]
Linked Question	Linked::
Order in Linked Questions	LinkedOrder::