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A 72-year-old white man is seen in the clinic with complaints of increasing dyspnea on exertion and orthopnea. The patient recently moved to the city and has records of a recent hospitalization four months ago for dyspnea upon minimal activity, increasing fatigue, and orthopnea. The patient has a long-standing history of asthma and diabetes. Medications at this time include inhaled steroids, inhaled beta-agonists, and glyburide. ACE inhibitors and furosemide were started two months ago.
Vital signs are: pulse 100/min, respirations 24/min, and blood pressure 154/94 mm Hg. Cardiovascular examination reveals a regular rate and rhythm, and an S4 is present. Bibasilar crackles are evident in the chest. There is no wheezing. There is a trace bilateral pedal edema in the extremities, and routine labs are normal, except for a BUN of 42 mg/dL and a creatinine of 1.9 mg/dL. An EKG shows a sinus rhythm with left ventricular hypertrophy. Chest x-ray shows cardiomegaly and increased vascular congestion. Labs four months ago showed a BUN of 27 mg/dL and a creatinine of 1.2 mg/dL. Echocardiogram shows left ventricular hypertrophy and an ejection fraction of 57%.
What is the next step in management in the management of this patient?
(A) Increase the dose of furosemide
(B) Restrict salt and fluids and reschedule a return appointment in four weeks
© Increase the dose of ACE inhibitors
(D) Add digoxin
(E) Start the patient on carvedilol
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d?? as he is goin into CHF...??
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Restrict salt and fluids and reschedule a return appointment in four weeks
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kaplan says, diastolic chf- if crackles + -> furosemide
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If adding Furosemide, it can be useful in this patient (pul crackles and trace of edema). However, it is careful to know the previous dose of furosemide and the actual intravascular volume of this patient, because he is on milde uremia ( increase BUN and Creatinine). Clinically I choose Furosemide before giving a try on Digoxine (have potential toxicity on this vignette). One more important clue is EF 57% which is not an indication of Digoxine b4 the diuretics and vasodilators, as this patient has symptoms (dyspnea, increase vascular marking on CXR)
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If you give digoxin this patient will improve his ejection fraction( digoxin is positive inotropic), he is in CHF and the treatment is diuretic plus digitalics. If we improve his eyection fraction we are also improving his renal function, he has a prerenal azotemia because the perfution is bad.
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furosemide as volume reduction is necessary in the patient
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1. Pt E.F of less 50%
--Chronic Chf = Dig
--Acute CHF = Dobutamine
2. Pt w/ E.F of greater 50%
--BB or CCB
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CMDT-
digoxin shd be used for pts who remain symp when taking diuretics and ACEI.
carvedilol- is non selective b blocker n here the pt is a known asthmatic.
sith r u sure of the ans?
