Question

A 71 year old male with a history of coronary artery disease and congestive heart failure presents with worsening dyspnea on exertion, orthopnea, and peripheral edema over the past week. Two years ago, he had a coronary stent placed in his circumflex artery. Catheterization at that time showed an ejection fraction of 25%, and since that time the patient had been stable with medical therapy. Past medical history also includes diabetes, hypertension, and peripheral arterial disease. Current medications include clopidogrel, lisinopril, propranolol, bumetanide, spironolactone, glipizide, and metformin. Physical examination reveals diffuse crackles bilaterally extending from the lung bases to two-thirds of the way up the lung fields. An S3 is heard, and there is 3+ pitting edema of the lower extremities bilaterally. Chest x-ray shows cardiomegaly and pulmonary edema in a ""bat wing"" pattern. The patient is admitted to the hospital, placed on a fluid restriction, and treated with intravenous furosemide. Following a net diuresis of 3 L, the patient feels much better. Which of the following is the next most appropriate step in the management of this patient?

A. Measurement of BNP
B. EKG
C. ABG
D. Increase propranolol
E. Endomyocardial biopsy

Answer 1

The next most appropriate step is to measure BNP (B-type natriuretic peptide) to confirm the diagnosis of heart failure and guide further management.

Step-by-step explanation:

The next most appropriate step in the management of this patient would be A. Measurement of BNP (B-type natriuretic peptide).

BNP is a hormone produced by the ventricles of the heart in response to increased stretching of the myocardium, which occurs in heart failure. The level of BNP in the blood is used as a diagnostic and prognostic marker for heart failure.

In this case, the patient's symptoms, physical examination findings, and chest x-ray findings are all consistent with the diagnosis of heart failure. Therefore, measuring the BNP level would help confirm the diagnosis and guide further management.