doyoudig
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2.) A 56 year-year-old male was referred to you with progressive easy fatigueability, moderate exertional dyspnea and two pillow orthopnea of a 1 year duration.
Relevant physical findings include BP 104/64 mm Hg, pulse 104/min and unlabored repirations at 20/min. Neck veins are engorged 3 cm above the clavicle at 30 degrees and the abdomino-jugular (also referred to as hepato-jugular) reflux is positive. The apical impulse is located two cm lateral to the left mid-clavicular line in the 6th interspace. Soft S3 and S4 gallops together with a grade 2/6 holosytolic murmur are heard at the apex. There are bibasilar inspiratory rales and 2+ pitting edema of the legs.
Chest x-ray reveals moderate cardiomegaly with pulmonary congestion. EKG shows a sinus mechanism with a CLBBB and frequent unifocal premature ventricular contractions. Echocardiography reveals a left ventricular end-diastolic dimension of 62 mm with global hypokinesia, EF of 38% and moderate MR. The inferior vena cava is moderately distended and demonstrates poor inspiratory collapse.
Which one of the following is initially indicated in the managment of the patient ?
A. Furosamide
B. Enapril
C. Amiodarone
D. Beta-blocker
E. Digoxin
Pls Provide ur reasoning and how u would Manage this Pt including initial and next steps and why??
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| GOGETA
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arlete where are you
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| DrVirgo
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A
He has CHF with pulmonary edema. First Step is to add a loop diuretic (FUROSEMIDE)- fastest way to get fluid out of the body adn decrease preload.
(O2 and Diuretics are always FIRST)...
Later on you can add Nitrates and morphine.
If he is still not better then Dobutamine (increases contractility AND vasodilates, so decreases after load).
And last line are ACE-I (decrease work load of heart) or ARBs (if can't tolerate ACE-I).
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| Justice
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Why can't we start from E. Digoxin?
I am not sure if furosemide would be safe with this blood pressure...
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| DrVirgo
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Justice wrote:
Why can't we start from E. Digoxin?
I am not sure if furosemide would be safe with this blood pressure...
I think Dig takes time to work so its not used first line as far as I know.
It can be used once the patient is stabilized and out of pulm. edema. (when he is ready for discharge to go home)...
Dig is given for systolic dysfunction sometimes and is usually given for Chronic Outpatient management along with Diuretic, ACE-I, and Beta blocker, (and ASA if pt has CAD also).
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| DrVirgo
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Also:
"Echocardiography reveals a left ventricular end-diastolic dimension of 62 mm with global hypokinesia,"
-If this means diastolic dysfunction, then Dig would be contraindicated.
Whats the right answer doyoudig?
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| cirus
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The ans is A
but later the pt will not need Morphine or nitrates, this is not Acute pulmonary edema, so after frusemide, u should give BBs & ACE
digitalis coud be added if still uncompensated to previous TTT (not used as first line anymore exept if CHF with tachyarrythmia)
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| arlete
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Here, GOGETA...
The answer is A. In regards to the low blood pressure, actually, once you make the cardiac effort easier decreasing the preload, the blood pressure goes up! We see that happening during practice, I don't know if they mention in books.
B, D and E are also indicated, but the question is "initially".
I don't think it's an acute pulmonary edema, either, and the patient will probably not need dopamine, dobutamine, nitrates (this would be dangerous because of the low blood pressure) at this time.
Amiodarone, only if there were complex arrhythmias (specially if we concluded it's ischemic cardiomyopathy), but then, we should consider an ICD with cardiac resynchronization, too.
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| kpmle2
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A. Furosamide ----initially indicated in the managment
what is the answer doyoudig
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| tamerbashir
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A
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| indidoc1
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initial- A
followed by B,
patient doesn't improve- dobutamine followed by digoxin
when the patient is stable, D
pacemaker fr LBBB
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| drduck
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A........nothing else good enough for acute management.
digoxin now a days is rarely used in practiced.
one shud always calculate the risk benifit ratio before using drugs like digoxin and similar drugs.
anyways best answer is A.
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