cirus
Forum Guru
Topics: 108
Posts: 740
|
A 58-year-old man is evaluated for acute dyspnea and hypotension of 1-hour’s duration. He was hospitalized for fevers, chills, and weight loss after a routine dental cleaning 2 weeks ago. Blood cultures were positive for gram-positive cocci. Echocardiography showed a mobile, soft-tissue density mass on the aortic valve. Therapy with intravenous vancomycin and gentamicin was begun, and the patient was doing well until this morning.
On physical examination, his heart rate is 108/min, respiration rate is 52/min, and blood pressure is 84/54 mm Hg. The cardiac apex is not displaced, murmurs are not heard, but diffuse crackles are present. After initiation of mechanical ventilation, portable chest radiography shows a normal cardiac silhouette and interstitial edema. Repeat electrocardiography shows sinus tachycardia and T-wave inversion in the inferior and lateral leads. Echocardiography shows severe aortic regurgitation.
Which of the following is the best immediate therapy for this patient?
( A ) Intravenous heparin and a ventilation-perfusion scan
( B ) Intravenous β-blockers and an angiotensin-converting enzyme inhibitor
( C ) Intravenous isoproterenol and nitroprusside
( D ) Intravenous furosemide and an aortic balloon pump
( E ) Left heart catheterization
|
| ansalshah
Forum Newbie
Topics: 3
Posts: 15
|
DD...whats answer
|
| dr.wad
Forum Senior
Topics: 3
Posts: 350
|
C...
|
| gr8doc
Forum Senior
Topics: 8
Posts: 210
|
A.
What do you think the diagnosis is?
Is it Myocardial ischemia secondary to the increased worklolad so demand & decreased supply? or something else?
I think ischemia is the issue here, so i would go for A, heparin & at the same time rule out PE by a VQ scan.
|
| gr8doc
Forum Senior
Topics: 8
Posts: 210
|
Where did you see this question Cirus? did they give you the right answer with the explanation?
or did they give you the wrong answer?
|
| cirus
Forum Guru
Topics: 108
Posts: 740
|
Correct Answer C The patient presents with aortic valve endocarditis, but quickly develops acute, severe aortic regurgitation with hemodynamic collapse. The physical findings of aortic regurgitation are often subtle or absent when aortic regurgitation occurs abruptly. Without time for compensatory left ventricular dilation, increased stroke volume and widened pulse pressure are absent, and the diastolic murmur may be brief or absent due to rapid equilibration of aortic and left ventricular pressures. Echocardiography confirms the clinical suspicion of acute, severe aortic regurgitation, and immediate therapy should be aimed at hemodynamic stabilization before surgery. The medical management of acute, severe aortic regurgitation is aimed at afterload reduction to decrease the severity of regurgitation, inotropic agents to support blood pressure, and chronotropic agents (or temporary pacing) to increase heart rate and thereby decrease the diastolic interval and the severity of regurgitation. Nitroprusside and isoproterenol are appropriate first-line therapeutic interventions. β-Blockers should be avoided, because slowing the heart rate increases the diastolic interval and results in more aortic regurgitation. An intra-aortic balloon pump is contraindicated in the setting of severe aortic regurgitation. Left heart catheterization is not indicated before beginning medical therapy, and likely would not be performed before urgent surgery due to embolic risk in active endocarditis. There is no indication for anticoagulation.
|
| gr8doc
Forum Senior
Topics: 8
Posts: 210
|
Well, on reading this even i feel the answer should be C. But honestly speaking, i would not have thought like this & i wonder how many of us would have got this one right.
Anyways, Good question Cirus. Keep them coming in.
|
|
| |
| | | | | | | |
Similar forum topics