A 54-year-old man comes to the emergency department due to worsening shortness of breath for the last 3 days. His symptoms initially occurred with exertion but are now present at rest. The patient could not sleep last night because of a suffocating cough each time he tried to lie down. He considers himself generally healthy and states, "I've never had to see a doctor for any problems." Family history is remarkable for asthma and hypertension. Blood pressure is 162/86 mm Hg, pulse is 92/min, and respirations are 26/min. An x-ray of the chest is shown in the exhibit.
Which of the following is the most likely diagnosis?

Question

A 54-year-old man comes to the emergency department due to worsening shortness of breath for the last 3 days.  His symptoms initially occurred with exertion but are now present at rest.  The patient could not sleep last night because of a suffocating cough each time he tried to lie down.  He considers himself generally healthy and states, "I've never had to see a doctor for any problems."  Family history is remarkable for asthma and hypertension.  Blood pressure is 162/86 mm Hg, pulse is 92/min, and respirations are 26/min.  An x-ray of the chest is shown in the exhibit.  
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_38ab_633d_9249_839ebedf397a_MD0001_00 This patient has progressive dyspnea and orthopnea (cough when lying down), along with chest x-ray findings of prominent pulmonary vessels, patchy bilateral airspace opacities, blunting of the costophrenic angles (pleural effusions), and a fissure sign (created by fluid trapped between the right upper and middle lobe). These findings are consistent with acute decompensated heart failure (ADHF); chronic hypertension is a common cause of heart failure due to concentric left ventricular hypertrophy and resulting diastolic dysfunction. In ADHF, increased atrial and ventricular filling pressures are transmitted to the pulmonary vasculature, causing fluid transudation into pulmonary interstitial and alveolar spaces (cardiogenic pulmonary edema). The chest x-ray may also show Kerley B lines-short, horizontal lines perpendicular to the pleural surface that represent edema of the interlobular septa. Cardiomegaly (cardiac-to-thoracic width ratio >50%) is also common in heart failure, but it is difficult to assess on anteroposterior view due to magnification of the heart. (Choice B) Acute respiratory distress syndrome (ARDS), or noncardiogenic pulmonary edema, results from endothelial injury and pulmonary capillary fluid leakage; it is typically preceded by a precipitating event such as aspiration, sepsis, pneumonia, or trauma. The appearance on chest x-ray is similar to ADHF, but pleural effusions are typically less prominent with ARDS (mostly alveolar opacification is seen), and ADHF is more likely in the absence of a recent inciting event for ARDS. (Choice C) The chest x-ray in idiopathic interstitial fibrosis shows diffuse, reticular opacities typically associated with decreased lung volumes. Most patients have slowly progressive dyspnea and a nonproductive cough. (Choice D) Obstructive pulmonary diseases (eg, chronic obstructive pulmonary disease) are associated with hyperinflated lungs and a flattened diaphragm. Asthma is an exception as the chest x-ray is typically normal between exacerbations. (Choice E) The chest x-ray in pulmonary arterial hypertension reveals enlargement of the pulmonary arteries and right ventricle and absence of pulmonary edema. (Choice F) On chest x-ray, pneumothorax is demonstrated by a white, visceral pleural line with an absence of peripheral pulmonary markings. The mediastinum is often shifted away from the affected side in tension pneumothorax. Educational objective: The chest x-ray in acute decompensated heart failure typically shows prominent pulmonary vessels; patchy, bilateral airspace opacification; and blunting of the costophrenic angles due to pleural effusions. __________ References: Diagnostic value of B-Type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. (http://www.ncbi.nlm.nih.gov/pubmed/15006584)

A 54-Year-Old Man Comes to the Emergency Department Due to Worsening