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Old 10-20-2011
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A 59-year-old woman with congestive heart failure (CHF) has just been discharged after her third exacerbation in 3 months. Although she has been compliant with her diet and medications, and is closely followed by a nurse practitioner trained in outpatient CHF management, she has had trouble keeping her weight stable. She has been taking higher and higher doses of furosemide but continues to slowly gain weight and to suffer progressive edema and orthopnea. She is worried that she will continue to retain fluid and have to be admitted again. Which of the following is an appropriate additional medication to help manage her CHF and volume overload?
A. Ethacrynic acid
B. Hydrochlorothiazide
C. Intravenous albumin
D. Mannitol
E. Torsemide
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Old 10-21-2011
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B.hydrochlorthiazide??
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C. Intravenous albumin
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Old 10-21-2011
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B. Hydrochlorothiazide
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Old 10-21-2011
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B. Hydrochlorothiazide
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Old 10-21-2011
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The correct answer is B. Patients with edema refractory to increasing doses of a loop diuretic often benefit from the addition of a thiazide diuretic, such as metolazone or hydrochlorothiazide. In cases of severe intravascular volume depletion and reduced renal perfusion, such as congestive heart failure, sodium reabsorption that is blocked in the loop of Henle is simply reabsorbed in the distal tubule. A thiazide can block this distal reabsorption, creating a synergistic diuresis when used with a loop diuretic.

Ethacrynic acid (choice A) and torsemide (choice E) are both loop diuretics. Although different loop diuretics have different bioavailabilities, switching agents or adding another agent in the same class is unlikely to improve this patientís diuresis.

Intravenous albumin (choice C) is a strategy that has been used in refractory edema to increase the oncotic pressure of the intravascular space, increasing glomerular filtrate and thus potentiating diuresis. Unfortunately, it has been proven only modestly effective, is extremely expensive, and is not appropriate for a woman who is to be managed as an outpatient.

Mannitol (choice D) is an osmotic diuretic and is not indicated in the treatment of CHF.
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