CINIII
Forum Senior
Topics: 34
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a qt demonstrating -see the rt rx and if the step bfr it is in the options or not.
this has been a frequent trend of connard's qts.
Record # 66
Question/Fact:
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
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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| doyoudig
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I thought we go straight to Emergency Surgery???
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| Justice
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doyoudig wrote:
I thought we go straight to Emergency Surgery???
Man, you are right, you transfer the Pt into OR, but dropping the BP down would safe his life... This would be the requested "initial intervention", whereas surgery is treatment... This is similar to aortic dissection - you do TEE, but before that it is imperative to lower the PB to preclude complete rapture...
I personally hate Fischer's Qs, but sometimes I see some sense between lines...
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| doyoudig
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But his BP is 120/70?? Thats why I don;;t get why we do not take him to surgery 1st
Where are the info on this Pt being Unstable????
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| Justice
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doyoudig wrote:
But his BP is 120/70?? Thats why I don;;t get why we do not take him to surgery 1st
Where are the info on this Pt being Unstable????
I was also confused by this word, and thought it was about hemodynamically-unstable Pt, but then I realised that it is about the nitroprussid... That's why it is safe to give it IV and easly to titrate...
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| doyoudig
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ok thx so I guess if this came up I will go for IV Nitro unless CI 1st while preping for surgery
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| ssrpk
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BP: 120/70...seems stable, but remember that appearance of shock or hemodynamic instability can be deffered by maximally stimulated sympathetic system, so always correlate the blood pressure with heart rate which is 120/min in this case, which heralds hemodynamic collapse.
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