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A 60-year-old woman comes to your office with complaints of progressive fatigue. She is unable to make it through the day without tiring and hasn't been sleeping well due to waking up in the middle of the night short of breath. She is also concerned about a 10-pound weight gain over the past month. She has a past medical history of hypertension, hypercholesterolemia, and diabetes mellitus. Her medications include metformin, atenolol, hydrochlorothiazide, and atorvastatin. The doses haven't changed over the past two years. Vital signs are: blood pressure 167/96 mm Hg, heart rate 78/min, and respiratory rate 20/min. There is some mild jugular venous distension at 30 degrees, bibasilar rales, a holosystolic murmur at the apex radiating to the axilla, and a mild pitting edema of the ankles. Which of the following would be appropriate at this time?
(A) Echocardiogram to determine direction of action
(B) Digoxin
© Increase the dose of atenolol
(D) Start ACE inhibitors
(E) Stop the atenolol
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Think LV dysfunction with activation of the R-A-A system thus worsening dyspnea and adema. I would say start ACE inhibitors, lower salt and fluid intake, and do echo to determine ejection fraction.
DDDDDDDDD.
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DDD
IT WILL COVER BOTH BP & PUL EDEMA
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A, I will do TTE; transthoracic ech to determin the structure of the hear, and ejection fractin. but regardless of the outcom of the ech, this patient needs ACE
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which one you do first, you do ech to see LV, or start her immediatly on ACE and the do ech?
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Answer:
(A) Echocardiogram to determine direction of action
Explanation:
At this point, there is not enough information to determine if this is systolic or diastolic cardiac dysfunction. Longstanding hypertension can lead to either type of cardiomyopathy. If an S3 gallop was heard or an echocardiogram confirmed a low ejection fraction, then choice D, ACE inhibitors, would be correct. If an S4 was heard or an echocardiogram definitely showed diastolic dysfunction, then choice C, increasing the beta-blockers, would be the correct choice for treating diastolic dysfunction. Choice B, adding digoxin, would not be appropriate at this time. Digoxin is only helpful to decrease symptoms in systolic dysfunction. If the patient still has symptoms of dyspnea after starting an ACE inhibitor, then adding digoxin to relieve symptoms would be appropriate. Beta-blockers are appropriate for both systolic and diastolic dysfunction, so choice E, stopping the atenolol, is not appropriate. The best data for evidence for a decrease in mortality are for carvedilol and metoprolol, although it is probably an effect of the entire class of medications. Switching the diuretic to a loop diuretic, such as furosemide, and starting a salt-restricted diet are generally appropriate for all forms of congestive failure.
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Maddy143
you are great, you covered it all....thank you
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