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NBME 24 Answers

nbme24/Block 1/Question#43 (13.9 difficulty score)
After completing 6 courses of chemotherapy ...

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nwinkelmann  What is the clue that this is not pulmonary fibrosis? How do I decide between Doxorubicin and Bleomycin? +  
ilikecheese  Also both bleomycin and methotrexate cause pulmonary fibrosis, so that helped me rule both those out and focus on the HF instead of the pulmonary symptoms +4  
adisdiadochokinetic  The S3 gallop and enlarged heart together are very strong evidence for heart failure. It's much more likely for heart failure to cause interstitial edema than for pulmonary fibrosis to directly cause heart failure. +8  

Doxorubicin = Cardiac problems Bleomycin = Pulmonary problems One hint to tell that it's cardiac and not pulmonary is the BILATERAL crackles/effusions since blood is backing up it would affect both lungs while Bleomycin could present as unilateral. Main though thing is the S3 which makes it automatically cardiac-related (dilated cardiomyopathy) and not pulmonary so the answer is doxorubicin.