Kamsi
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A 45-year-old man presents with the sudden onset of nausea, vomiting, and chest discomfort, which started three hours ago. The patient took Maalox and Tums, but they didn't relieve his symptoms. His past medical history is significant for gastroesophageal reflux disease.<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
Vital signs: temperature 100.9 F (rectal), heart rate 40/min, blood pressure 86/52 mm Hg, and respiratory rate 26/min. Physical examination is significant for jugular venous distension with clear lungs. EKG shows ST elevation in II, III, and AVF, and the chest x-ray is normal. Oxygen saturation is 98% on room air. Which of the following would be the most appropriate initial therapy?
(A) Aspirin, nitroglycerin, morphine, ACE inhibitors
(B) Transcutaneous pacemaker
(C) Thrombolytics
A 36-year-old woman is seen in the emergency department for palpitations and exercise intolerance. She is mildly short of breath but denies chest pain. Her symptoms began two hours prior to arrival. She states that she has had similar episodes in the past but has never been diagnosed. There is no other significant past medical history, and her social history is unremarkable. Her vital signs are normal. An EKG at that time was also normal. She is started on oxygen by nasal canula at 2 liters per minute and was admitted for observation due to her shortness of breath. Later that evening, she complains of worsening palpitations, and an EKG reveals atrial fibrillation. Her vital signs are: blood pressure 110/68 mm Hg, pulse 138/min, respirations 20/min, and temperature 98.4 F. What is the most appropriate medication at this time?
(A) Adenosine 6 mg IV push
(B) Procainamide infusion of 20 mg/min
(C) Amiodarone
(D) Diltiazem intravenously
(E) Digoxin orally
(F) Transesophageal echocardiogram
Can someone explain when to use the antiarrhymic drugs.
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| dermatology
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i wud go with answer A for both questions ...
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| gordon
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1. B-Transcutaneous pacemaker
This patient had MI with right coronary artery occlusion. The SA was also affected. Since this patient is hemodynamic unstable with slow heart rate ( 40), the Transcutaneous pacemaker should be the initial management.
2. E----Digoxin orally
Digoxin, Procainamide and Amiodarone are all the drugs of choice for AF. However, the first line durg is digoxin when the patient is hemodynamic stable, Procainamide and Amiodarone can be used after digoxin failed.
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| arlete
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First: C
It's a RV MI, so the bradycardia is probably sinusal and must be treated with atropin, not percutaneous pacemaker. We must give volume to improve the blood pressure. The three drugs proposed after "Aspirin" will probably decrease the BP even more. Thrombolytics are indicated, since it's been 3 hours of onset of CP.
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| arlete
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Second: B
It's an acute FA paroxysm, so the intention is to cardiovert the patient to sinus rhythm, not control the ventricular response. Because it's been less than 48 h, no need for TEE, there was no time for thrombi formation.
Drugs for cardioversion: classes Ia, Ic and III; for rhythm control: II and IV and digoxin (but remember it takes a while before it starts working).
Adenosine and Diltiazem are primarily used for PSVT.
Procainamide has less dangerous side effects than amiodarone, that's why I would go for it.
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| njcjzy
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Kamsi, what are your answers? 
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| Kamsi
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sorry guys the Ist Q options are not complete
they are:
(A) Aspirin, nitroglycerin, morphine, ACE inhibitors<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" />
(B) Transcutaneous pacemaker
(C) Thrombolytics
(D) Atropine sulfate
(E) Metoprolol
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| arlete
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D for first, then.
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| dr.wad
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1- B
2_D ( i guess digoxin orally will give delayed onset of action )
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| dermatology
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D for first one
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| starcraftbw
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1. B
2. D
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| Kamsi
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1 D
2 E
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| arlete
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Where did you get these questions from?
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| spmvj
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1.D
2.D
1.This patient has symptomatic bradycardia due to acute inferior wall infarction.So we can give atropine.Only if the pt does not respond to atropine we can go for pacemaker.ChoiceA cannot be correct as those drugs might worsen the hypotension.I'm not sure of giving thrombolytic therapy in a pt who has past H/o GERD.Obviously metoprolol is also contraindicated in this patient.so I go for D.
2.In this patient who has acute AF with no hemodynamic compromise ,the first thing to do is to control the ventricular rate by giving drugs such as beta blockers,ca channel blockers, or digoxin. Oral Digoxin is not useful for acute condition as it takes longer to act. After lowering the heart rate we can give antiarrhythmics to convert the rhytm to normal sinus.TEE is indicated only for the pt with AF>48hours who are not anticoagulated.
but in this pt basically I would like to give beta blocker because he has palpitations.It is not given in the choices.So I go in for diltiazam.
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| peraspera
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This qs came from
http://www.amazon.com/Conrad-Fischers-Internal-Me...
Highly reccomend this book, there are many important points & informations you cannot find in the Kaplan's notes. Good tool for Step2,3
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| arlete
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Are you sure Dr. Fischer gives Digoxin orally for patients with paroxysmal atrial fibrillation? That sounds very odd to me!
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| dermatology
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is this book for usmle step 2 and 3 ??? or for internal medicine boards ???
i hope the questions are not so difficult in usmle exams ..... i willl surely fail ...
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| doyoudig
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1st D - Atropine Most Appropriate
2nd D - CCB (even though BB are preffered)- rate Control comes 1st regardless of chronic or acute -- Pts Pulse is 138/min
Dig is preffered in Pts w/ AF d/t CHF which is not the case here
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| doyoudig
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GERD is not a CI to Thrombolytics
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| peraspera
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Q#2.
(D) Diltiazem intravenously
Explanation:
The most important initial step in this patient is to control the heart rate. Diltiazem will lower the hear rate rapidly, as will intravenous beta-blockers, such as metoprolol. Adenosine is effective for supraventricular tachycardia but is not effective for atrial fibrillation. Procainamide is useful to convert atrial arrhythmias to sinus rhythm but would not be useful until the rate has been controlled with an agent that blocks down the AV node. Digoxin can also be used to control the rate but even intravenously does not work as rapidly as verapamil, diltiazem, or beta-blockers. Oral digoxin would be far too slow. Amiodarone is very good at maintaining a patient in sinus rhythm after being converted by medications or electrical cardioversion. Although an echocardiogram would be useful in determining the etiology of the rhythm disturbance and if there is a thrombus present, it would not be as acutely important as slowing the heart rate. Even if there were a thrombus, you still would need to slow the rate. ( IM Qbook by Conrad Fischer)
to dermatology-the questions are not easy, but i like it. It's great learning tool. I think it's for both steps.
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| elitoki
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I think the answers had been posted from Kamsi, and that said
Kamsi wrote:
1 D
2 E
FOR second one in FA gives you ABC's
Afib treatment:
A - anticoagulant
B - beta blocker
C - calcium channel blocker
D - Digoxin.
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| arlete
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What I don't agree is Digoxin orally in an acute presentation.
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| gordon
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This patient has what is called" lone atrial fibrillation" Since palpitations is her only complaint. She has had AF in the past. Although she had acute presentation this time.
According to the UW, lone atrial fibrillation only need Aspirin for anticoagulants, even do not need warfarin. Since this patient' vital signs are normal. You don't have to treat her so rushly. Oral digoxin is the best way for her.
You should know that IV those drugs, such as amiodarone, dronedarone, procainamide, ibutilide, propafenone or flecainide, are called chemical cardioversion. Apparently, she doesn't need it.
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| starcraftbw
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^^^ read the question again......... her pulse is 138 and you call her vs normal?
why not calcium blockers?
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| elitoki
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elitoki wrote:
Diltiazem has effect on heart but is not specific.
I think if there were verapamil instead diltiazem, my answer will be calcium channel blocker.
Ok! I got it now. I had to read again your answers, and I change my anwer for Q2. D diltiazem- calcium channel blocker!!!
Thanks guys!
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