View source for WBR0450

{{WBRQuestion
|QuestionAuthor=Neeraja Danda M.B.B.S
|ExamType=USMLE Step 2 CK
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|MainCategory=Internal medicine
|MainCategory=Internal medicine
|SubCategory=Cardiovascular
|Prompt=A 55 year old male  presents to his primary care physicians  complaining of dyspnea on exertion for the last 3 months. His past medical history is significant for hypertension, diabetes mellitus and myocardial infarction at the age of 52.Vitals include pulse rate 82/min, blood pressure 140/90 and respiratory rate of 22/min. On cardiac auscultation,  a low pitched sound is heard after S2 at the  apex. Lung auscultation reveals bilateral rales at the lung bases. What is best initial test to diagnose this patient’s condition?
|Explanation=Myocardial infarction is one of the major causes of cardiac failure. Hypertension can also lead to heart failure by resulting in cardiac muscle abnormality such as left ventricular hypertrophy. Dyspnea on exertion is the most characteristic presentation in cases of heart failure. S3, rales, orthopnea, edema and jugular venous distension can also be seen in congestive cardiac failure. This patient’s presentation with dyspnea on exertion and the cardiac auscultation findings suggest heart failure. A low pitched sound after S2 can be an S3 gallop, which is characteristic of congestive heart failure. The patient’s history of hypertension and myocardial infarction are likely responsible for causing congestive heart failure.The best initial test to diagnose heart failure is a transthoracic echocardiogram.

'''Educational Objective:'''Transthoracic echocardiogram is the best initial test in evaluating heart failure.

'''References:''' Page 75,76,77,78 Master the boards step 2 CK second edition

|AnswerA=Nuclear ventriculography
	

|AnswerAExp='''Incorrect'''Nuclear ventriculography is only used when very accurate evaluation of wall motion abnormalities is required. It is not routinely used and not an initial test
|AnswerB=Transthoracic echocardiogram
|AnswerBExp=Transthoracic echocardiogram is the best initial test in evaluating heart failure.
|AnswerC=Transesophageal echocardiogram
|AnswerCExp='''Incorrect''' Transesophageal echocardiogram accurately evaluates valve function and diameter .However, it is not the initial test in evaluating congestive heart failure.
|AnswerD=Holter monitor
|AnswerDExp='''Incorrect'''Holter monitor is used to detect arrhythmias as the cause of heart failure if the patient has palpitations and heart failure.
|AnswerE=Complete blood count
|AnswerEExp='''Incorrect'''Complete blood count is useful when anemia is suspected as the cause of heart failure. 

|RightAnswer=B
|WBRKeyword=Congestive heart Failure, Transthoracic
|Approved=Yes
}}