06-10-2009, 10:19 AM
A 71-year-old man with a 50-pack-year smoking history is brought by ambulance to the emergency department with severe shortness of breath. On arrival, you note the patient is sitting, leaning forward and supporting himself with arms extended and hands on knees. His shortness of breath began 45 minutes ago while he was at rest. He also began coughing at this time. He denies chest pain, headache, focal numbness or weakness, difficulty speaking, or other complaints. His medical history is significant for asthma, class II congestive heart failure (CHF), and cardiovascular disease with a three-vessel coronary artery bypass graft (CABG) 10 years ago. His medications are albuterol and steroid inhalers, enalapril, carvediol, furosemide, and digoxin. On examination, the patient appears anxious and diaphoretic. Vital signs are temperature: 100.1°F; BP: 150/95; HR: 115; RR: 28. There are coarse crackles in both lung fields and an expiratory wheeze. Cardiac examination reveals an S3 gallop. Abdominojugular reflux is positive, there is 2+ pitting ankle edema. Pulse oximetry indicates 82% O2 saturation. Arterial blood gas (ABG) values are pH: 7.33; Pao2: 66; Pco2: 48; HCO3: 27.
Item 1 of 3
What would best support a diagnosis of an acute CHF exacerbation as the etiology of the patient's respiratory distress?
A. Dyspnea improved with administration of morphine sulfate
B. Echocardiography showing ejection fraction less than 35%
C. No improvement in PaO2 with bronchodilator administration
D. O2 saturation improved with dobutamine administration
E. Presence of lower extremity pitting edema
Item 1 of 3
What would best support a diagnosis of an acute CHF exacerbation as the etiology of the patient's respiratory distress?
A. Dyspnea improved with administration of morphine sulfate
B. Echocardiography showing ejection fraction less than 35%
C. No improvement in PaO2 with bronchodilator administration
D. O2 saturation improved with dobutamine administration
E. Presence of lower extremity pitting edema