Question of the Week # 341

341) A 78 year old man presents with progressively increasing shortness of breath. He has a 100 pack year history of smoking. His past medical history is significant for chronic obstructive pulmonary disease, coronary artery disease and congestive heart failure. He has been admitted several times in the past one year for Congestive heart failure exacerbations which resulted from his non-compliance with diet and medications. His medications include aspirin, metoprolol, enalapril, and spironolactone and tiotropium inhaler. On examination, he is afebrile with respiratory rate 24/min, pulse 106beats/min, blood pressure 140/90. Breath sounds are decreased and there is dullness to percussion on the left side of the chest.  Heart sounds are regular and there is no S3 gallop. A 2D echocardiogram reveals ejection fraction at 30% and a brain natriuretic peptide 250 pg/ml (Normal less than 100pg/ml) . An EKG reveals changes consistent with left ventricular hypertrophy. A Chest X-ray is shown below:

Which of the following is the most appropriate next step in management?

A) Intravenous Furosemide

B) Tube Thoracostomy

C) Intravenos Nitroglycerin

D) Needle thoracentesis

E) Implantable Cardioverter-Defibrillator (ICD) placement

10 Responses

  1. A) Intravenous Furosemide

    • B

    • Although Bilateral pleural effusion is the most common with CHF…unilateral pleural effusion esp right sided is frequently seen.So diagnostic needle thoracentesis is needed only when there is unilateral (esp left) pleural effusion before proceeding to treatment ??

      D)Needle thoracentisis

      • Dr.Red could you please clarify this? thankyou!

      • Hi shruti…Yes, correct. Isolated Left sided unilateral effusion is uncommon in CHF even during exacerbation that too in the absence of other clinical signs and only a borderline BNP. Needle thoracenresis should be done to make sure we are not missing something in such atypical presentaions ( eg: cancer)
        If this were a bilateral effusion or a right sided effusion with CHF signs, no need to worry – treat CHF and follow up x-ray to see if the effusions resolve ( no needle thoracentesis needed in such cases)

      • Thank you so much!!

  2. A

  3. d

  4. It is not acute exacerbation of CHF.
    There is no S3, BNP is not typically high (BNP should be >500pg/ml in CHF) and bilateral crepitation. I think it is left sided pleural effusion. To relieve shortness of breath…..
    So, I will go with
    D) Needle thoracocentesis

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