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+--- Thread: good one but cardio.. - diamox79 (/showthread.php?tid=193496)
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good one but cardio.. - diamox79 - ArchivalUser - 06-10-2007
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
© Transesophageal echocardiogram
(D) Start coumadin
(E) Mitral valvotomy
(F) Electrical cardioversion
0 - ArchivalUser - 06-10-2007
CCCCCC
0 - ArchivalUser - 06-10-2007
A........
0 - ArchivalUser - 06-10-2007
AAA
0 - ArchivalUser - 06-10-2007
read the q again...sammy n sriram...there is a catch..for now both of u are wrong...
0 - ArchivalUser - 06-10-2007
D.....?????
0 - ArchivalUser - 06-10-2007
dont u want to control the rate first....
0 - ArchivalUser - 06-10-2007
OK
GOT IT
B........
real good one
thugh v confusing options
0 - ArchivalUser - 06-10-2007
For electrical cardioversion , symptoms should be less than 48hrs duration. But here the patient is having symptoms from 3 days. so better to start warfarin(comadin)
0 - ArchivalUser - 06-10-2007
here is the explanation guys...B..is the answer
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.