A 68-year-old male with a history of severe COPD presents to the emergency department with acute onset dyspnea, tachypnea, peripheral edema, and jugular venous distention. He reports worsening fatigue and shortness of breath over several weeks, now occurring at rest. Physical exam reveals cyanosis, a loud P2 heart sound, and hepatomegaly. An echocardiogram demonstrates right ventricular dilation with right ventricular hypertrophy and reduced right ventricular systolic function. Which of the following is the most likely diagnosis?
Acute left-sided heart failure
Cor pulmonale
Pulmonary embolism
Dilated Cardiomyopathy
The Correct Answer is B
A. Acute left-sided heart failure: Left-sided heart failure typically presents with pulmonary congestion, dyspnea, orthopnea, and pulmonary rales. While it can eventually lead to right-sided symptoms, this patient’s presentation is dominated by right-sided signs—jugular venous distention, peripheral edema, hepatomegaly—without primary pulmonary edema, making left-sided failure less likely.
B. Cor pulmonale: Cor pulmonale is right ventricular enlargement and dysfunction caused by chronic pulmonary hypertension, often secondary to chronic lung diseases such as COPD. Features include peripheral edema, cyanosis, elevated jugular venous pressure, loud P2 due to pulmonary hypertension, hepatomegaly, and echocardiographic evidence of right ventricular dilation and hypertrophy. The patient’s history of severe COPD and chronic hypoxia strongly supports this diagnosis.
C. Pulmonary embolism: Pulmonary embolism can cause acute right heart strain and dyspnea, but it usually presents suddenly with chest pain, hemoptysis, and often without chronic signs such as peripheral edema or hepatomegaly. Echocardiography may show right ventricular dilation acutely, but chronic hypertrophy is not typical in isolated PE.
D. Dilated cardiomyopathy: Dilated cardiomyopathy affects both ventricles with progressive systolic dysfunction, leading to biventricular heart failure. While it can cause right-sided symptoms, the patient’s chronic COPD history and predominance of right-sided findings point to cor pulmonale rather than primary dilated cardiomyopathy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
A. Bronchial asthma:Bronchial asthma is primarily an inflammatory airway disorder associated with atopy, allergens, and genetic predisposition. Alcoholism is not a recognized major risk factor for the development of asthma, which involves reversible bronchoconstriction rather than infectious or aspiration-related pathology.
B. Chronic bronchitis:Chronic bronchitis is most strongly associated with long-term cigarette smoking and environmental irritants. While alcohol use may coexist with smoking, alcoholism itself is not the primary predisposing factor for chronic bronchial inflammation and mucus hypersecretion.
C. Diffuse alveolar damage:Diffuse alveolar damage, the histologic basis of ARDS, is typically triggered by severe systemic insults such as sepsis, trauma, or aspiration. Although alcohol abuse may increase susceptibility to infections, it is not the most common direct cause of diffuse alveolar damage.
D. Emphysema:Emphysema results from destruction of alveolar walls, most commonly due to cigarette smoking or alpha-1 antitrypsin deficiency. Alcoholism does not directly cause the protease-antiprotease imbalance responsible for alveolar destruction seen in emphysema.
E. Pulmonary abscess:Alcoholism predisposes individuals to aspiration due to impaired consciousness and depressed cough reflex. Aspiration of oropharyngeal contents introduces anaerobic bacteria into the lungs, leading to localized suppurative infection and cavitation, which characterizes a pulmonary abscess.
Correct Answer is A
Explanation
A. Bacterial pneumonia:This patient presents with acute onset of fever, chills, pleuritic chest pain, productive purulent sputum, and respiratory distress, all of which are classic signs of bacterial pneumonia. Alcoholism predisposes individuals to aspiration and impaired immune defenses, increasing the risk of bacterial lung infections, particularly from anaerobic or gram-negative organisms.
B. Chronic bronchitis:Chronic bronchitis is defined by a productive cough lasting at least three months per year for two consecutive years. While it causes chronic cough and sputum production, it does not typically present acutely with high fever, chills, and severe respiratory distress.
C. Emphysema:Emphysema involves chronic destruction of alveolar walls leading to dyspnea and hyperinflated lungs. It is a chronic, progressive disease and does not present with acute febrile illness or purulent sputum.
D. Laryngitis:Laryngitis affects the upper airway, causing hoarseness, sore throat, and cough. It does not cause purulent sputum, high fever, or severe dyspnea, and it is not a primary cause of lower respiratory distress.
E. Metastatic lung cancer:Metastatic lung cancer can lead to cough, hemoptysis, or dyspnea over weeks to months but usually does not cause sudden-onset fever, chills, and thick purulent sputum. The acute presentation points toward an infectious etiology rather than malignancy.
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