04-24-2007, 06:53 PM
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
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