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  #1  
Old 05-21-2012
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Heart Post MI Pulmonary Crackles?

A 65-year-old male presents to the emergency department with substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. Since the pain started, the patient has vomited twice. The pain adiates to his left arm and does not remit with sublingual nitroglycerine. EKG shows 2 mm ST elevations in the anterior leads. On physical examination, the patient's temperature is 36.9•c (98.4.F), blood pressure is 11 0/70 mm Hg, pulse is 60/min, respirations are 32/min, and oxygen saturation is 90% on 4L oxygen by nasal canula. Cardiac exam reveals a muffled S 1 and S2 and the presence of an S3. Lung exam reveals basilar crackles that extend halfway up the lung fields bilaterally. Which of the following is the best next step in managing this patient?

A. Metoprolol
B. Digoxin
C. Furosemide
D. Spironolactone
E. IV fluids
F. Verapamil
G. Amlodipine
H. Quinidine
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Old 05-21-2012
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Guess is C.......
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Old 05-21-2012
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C. Furosemide
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Old 05-21-2012
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Quote:
Originally Posted by tyagee View Post
A 65-year-old male presents to the emergency department with substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. Since the pain started, the patient has vomited twice. The pain adiates to his left arm and does not remit with sublingual nitroglycerine. EKG shows 2 mm ST elevations in the anterior leads. On physical examination, the patient's temperature is 36.9•c (98.4.F), blood pressure is 11 0/70 mm Hg, pulse is 60/min, respirations are 32/min, and oxygen saturation is 90% on 4L oxygen by nasal canula. Cardiac exam reveals a muffled S 1 and S2 and the presence of an S3. Lung exam reveals basilar crackles that extend halfway up the lung fields bilaterally. Which of the following is the best next step in managing this patient?

A. Metoprolol
B. Digoxin
C. Furosemide
D. Spironolactone
E. IV fluids
F. Verapamil
G. Amlodipine
H. Quinidine
-it's acute heart faliuar ,so A.is contraindicated. B.no arithmia,c. relive symptoms but doesn't lower mortalty;d. lower mortalaty ,E :worse symptoms,fgh:not approprate.&conard ficher say :let mortalty gauid u.but ithink D. is for chronic mangment ,so am going for c.
-acute HF:O2,netrate,morphine,duratic,if pt not respond add,dobutamin.
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Old 05-21-2012
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Bibasilar crackles halfway up the lung fields means he's accumulating fluid in his lungs secondary to left heart infarction.
So first step is most likely to clear his lungs i.e. furosemide.

However had 'aspirin' been a choice would that be the next best step or furosemide?
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Old 05-21-2012
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Quote:
Originally Posted by um aala View Post
-it's acute heart faliuar ,so A.is contraindicated. B.no arithmia,c. relive symptoms but doesn't lower mortalty;d. lower mortalaty ,E :worse symptoms,fgh:not approprate.&conard ficher say :let mortalty gauid u.but ithink D. is for chronic mangment ,so am going for c.
-acute HF:O2,netrate,morphine,duratic,if pt not respond add,dobutamin.
coolll analysis
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Old 05-22-2012
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furosemide (the asker also bold the important point pt's lung are drowning & has severe dyspnea)

symptomatic rx in MI:
if chest pain: nitrate --> morphine
if dyspnea with pulmonary edema: loop (with caution) --> Dobutamine

and if the question put aspirin, YES chose it first (cuz of mortality things & bla bla bla u knoww )
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