USMLEGladiator
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A 56-year-old man presents to the emergency department with complaints of dyspnea on exertion for the last three days. The patient is normally able to walk about eight blocks without any problems, but now can only walk one. He doesn't take any medications and denies alcohol and tobacco use. Vital signs are: temperature 98.7 F, pulse 126/min, blood pressure 124/68 mm Hg, and respirations 18/min. The jugulovenous pressure is elevated, and there is a soft diastolic rumble at the apex with an opening snap. Rales are present at both bases. EKG shows atrial fibrillation at a rate of 126/min. What is the next best step in the management of this patient? (A) Furosemide (B) Diltiazem (C) Transesophageal echocardiogram (D) Start coumadin (E) Mitral valvotomy
(F) Electrical cardioversion
c c c.
unstable(pul edema)---->TEE--->DC cadioversion---->then anti coagulation--->then ccbs/digoxin to control sinus rhythm
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| hero
Forum Guru
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actually, he is hemodynamicly stable - his BP. no cardioversion.
My guess D.
Edited by hero on 06/13/08 - 10:19 PM
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| hero
Forum Guru
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the best in general - valvulotomy, don't know could it be "next best"
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| janan
Forum Newbie
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With elevated Jvp, and rales at the lung base...Is he haemodynamically stable?
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| DrAlex_76
Forum Guru
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the pt is in Pulmonary edema. Diuretic is the first hand of choice.
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| hero
Forum Guru
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janan wrote:
With elevated Jvp, and rales at the lung base...Is he haemodynamically stable?
it's CHF
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| Anand007
Forum Senior
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there is no apico-pulse delay in this case.. EKG n peripheral pulse are d same here..which means left ventricle is beating very fast ..and d atrial n ventricular contractions are not powerful to pump d blood forwards.. hence back pressure develops causing pulmonary edema and raised JVP... i think rate control is important here.. cardioversion is needed for immediate control.. with pulmonary edema, furosemide also could be d answer.. confusing !!
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| brutus25
Forum Junior
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A - every day of the week
This is MS leading to Pulmonary edema - give the man some FUROSEMIDE
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| brutus25
Forum Junior
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B - DILTIAZEM - Sorry man I wasn`t careful enough , jumped over the 126 bpm
Rate control very important in A.Fib
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| USMLEGladiator
ck, CS Finish by Feb09
Topics: 131
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(B) Diltiazem
Explanation:
This patient has a diastolic murmur and an opening snap consistent with mitral stenosis. All the therapies described may be useful in the management of mitral stenosis. As is often the case on board tests, all the answers are partially correct. The initial step is to relieve this patient's symptoms by controlling the heart rate. Ventricular filling is impaired by mitral stenosis. The ventricle fills during diastole. The rapid rate of atrial fibrillation shortens diastolic filling time and causes the symptoms. The only therapy listed in the answer choices that controls heart rate is diltiazem. Although furosemide will decompress the lungs, it will not slow the heart rate. And although he may eventually need balloon valvotomy, this would not be done before the heart rate has been controlled. Coumadin will eventually be needed; worrying about a clot that might form in a year is not as important as controlling the symptoms of dyspnea now. It is unlikely that anything found on an echocardiogram will make you not control the rate. The echocardiogram is needed but will not change the initial management. Electrical cardioversion is not indicated for several reasons. First, he is not acutely unstable. The dyspnea is on exertion, not right now. Second, with mitral stenosis and what is surely an accompanying left atrial dilation, he will probably revert back to atrial fibrillation. The more abnormal the atrium is anatomically, the harder it is to successfully cardiovert. Finally, you would not want to cardiovert atrial fibrillation in a patient with three days of symptoms without either a transesophageal echo to exclude a clot or without having given three weeks of anticoagulation prior to the cardioversion.
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