doyoudig
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58 y/o obese diabetic man, h/o alcoholism, presents to the ER with SOB via ambulance. He suddenly began SOB while watching TV at home. While in the ambulance he had begun to cough up sputum, no chest pain. He is 55pack-year smoker, drinks 40 units of alcohol a week.
PE: distress, breathing 60% oxygen through a facemask, unable to complete a full sentences, no chest wall tenderness, no murmur or rubs, asculation reveal fine crepitations throughout the chest. EKG not reveal ST segment elevation or depression. The patient does not improve with IV Furosemide, sublingual Glyceryl trinitrate and Morphine. He is placed on IV Dobutamine. Ten minutes later, his conditions remains unchanged. His BP 126/79 mm Hg. What is the next best step in management?
a. Dopamine
b. Echocardiography
c. Hydralazine
d. MUGA scan
e. Synchronized cardioversion
f. Verapamil
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| Justice
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This is PE most likely
I go with (b) Echocardiography to look for other thrombi...
Nothing else would be needed from the list, but he really need heparin
Edited by Justice on 04/28/07 - 06:37 PM
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| sachida
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How can PE be diagnosed with echo? not sure what you wanted to say justice.
I do agree for echo, but i am bit confused.
Chronic alcoholism may actually predispose to bleeding then thrombosis.
and for PE best thing to do will be v/q or spiral CT.
ECG does not mention anything about rethym,
could it be mural thrombus?
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| vradojc1
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AF? Acute, not enough time for thrombus - cardioversion?
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| doyoudig
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The answer is C (Hydralazine)
Pt has acute pulmonary edema, secondary to L ventricular dysfunction. He does not imrove with IV Furosemide, Nitrate and Morphine and Dobutamine. Hydralazine also act by reducing after load then increase cardiac output but it is used in a second line in acute PE after Dobutamine has been used.
Personally I would have picked ECHO, to find the reason 1st before initaiting any other drugs
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| sachida
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I am confusing pulmonary embolism to pulmonary edema. 
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