Aashi
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A 65-year-old man presents to the hospital with complaints of chest pain of 8 hours' duration. The EKG reveals anterior wall ST elevation. The patient receives aspirin, oxygen, tissue-plasminogen activator, metoprolol, and intravenous nitroglycerin. His symptoms resolve, and serum chemistries reveal a peak CPK of 1,200 U/L and a CKMB of 80 U/L. The patient is transferred to the CCU. His subsequent hospital course is uneventful until Day 3, when the patient develops severe dyspnea. The blood pressure is 120/70 mm Hg, and the heart rate is 120/min. Physical examination reveals a new, loud, holosystolic murmur radiating to the axilla and bilateral rales. What would be the most appropriate initial intervention at this point?
(A) Heparin alone
(B) Heparin and furosemide
(C) Heparin and digoxin
(D) Sodium nitroprusside
(E) Surgery
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| drashishmahajan
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B
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| prathapdoctor
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Heparin and furosemide.
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| fox
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| Aashi
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what do u think the dx here guys
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| dr.wad
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( D ) Na nitroprusside the surgery.
this is acute mitral incompitence due pulpillary muscle dysfunction which occur in anterior infarction .
nitroprusside should be given to treat the acute pulmonary oedema, then surgery should be done .
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| Aashi
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Answer:
(D) Sodium nitroprusside
Explanation:
The patient presents with a ruptured mitral valve because of his recent myocardial infarction. The new systolic murmur, dyspnea, and rales are an indication of the rupture of the valve. It is also possible that he has a ventricular septal rupture (VSD). Both can give a systolic murmur. The mitral murmur is best heard at the apex, and a VSD is best heard at the lower-left sternal border. Therapy for both would be acute afterload reduction followed by surgical repair. Because he is so unstable, the ideal agent would be intravenous and readily titratable. Nitroprusside has an extremely short half-life and can easily be stopped or reduced if the blood pressure drops too far.
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| robin082006
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this is papillary rupture, but the answer is weird because BP here=120/70.
Use Nitroprusside will lead to hypotension.
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| prathapdoctor
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I am really despondent now,in harrison its clearly mentioned that in CHF after MI diuretics are the initial drugs of choice and ACE inhibitors can also be added.
But your explanation is given in CMDT. which book to follow and how to cope with these, in harrison no where mentioned about sodium nitroprusside in treatment of CHF in post MI.
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| Aashi
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Well abt ur q robin and dr pratap plss chk this link
http://www.emedicine.com/med/topic1571.htm ( UNDER MEDICAL TREATMENT)
"In less severe cases of papillary muscle rupture, vasodilators should be started to decrease afterload in an attempt to stabilize patients before surgery. This is often accomplished with intravenous nitroprusside"
I have pasted the part which is relevant to the q i posted..u may read more on this from the above link..
GL
Edited by Aashi on 03/05/07 - 08:33 AM
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| nadiabarati
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SO STRANGE!!!!
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| prod
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great info..thnx
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