dyspenic patient with Opening Snap...next step ? lasix or beta blocker or echo or warfarin ? - USMLE Forums
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Old 06-08-2012
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Default dyspenic patient with Opening Snap...next step ? lasix or beta blocker or echo or warfarin ?

A 56-year-old man presents to the emergency department with complaints of dyspnea on exertion for the last three days. The patient is normally able to walk about eight blocks without any problems, but now can only walk one. He doesn't take any medications and denies alcohol and tobacco use. Vital signs are: temperature 98.7 F, pulse 126/min, blood pressure 124/68 mm Hg, and respirations 18/min. The jugulovenous pressure is elevated, and there is a soft diastolic rumble at the apex with an opening snap. Rales are present at both bases. EKG shows atrial fibrillation at a rate of 126/min. What is the next best step in the management of this patient?
(A) Furosemide
(B) Diltiazem
(C) Transesophageal echocardiogram
(D) Start coumadin
(E) Mitral valvotomy
(F) Electrical cardioversion
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Old 06-08-2012
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Quote:
Originally Posted by tyagee View Post
A 56-year-old man presents to the emergency department with complaints of dyspnea on exertion for the last three days. The patient is normally able to walk about eight blocks without any problems, but now can only walk one. He doesn't take any medications and denies alcohol and tobacco use. Vital signs are: temperature 98.7 F, pulse 126/min, blood pressure 124/68 mm Hg, and respirations 18/min. The jugulovenous pressure is elevated, and there is a soft diastolic rumble at the apex with an opening snap. Rales are present at both bases. EKG shows atrial fibrillation at a rate of 126/min. What is the next best step in the management of this patient?
(A) Furosemide
(B) Diltiazem
(C) Transesophageal echocardiogram
(D) Start coumadin
(E) Mitral valvotomy
(F) Electrical cardioversion
E................????
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Old 06-08-2012
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Quote:
Originally Posted by tyagee View Post
A 56-year-old man presents to the emergency department with complaints of dyspnea on exertion for the last three days. The patient is normally able to walk about eight blocks without any problems, but now can only walk one. He doesn't take any medications and denies alcohol and tobacco use. Vital signs are: temperature 98.7 F, pulse 126/min, blood pressure 124/68 mm Hg, and respirations 18/min. The jugulovenous pressure is elevated, and there is a soft diastolic rumble at the apex with an opening snap. Rales are present at both bases. EKG shows atrial fibrillation at a rate of 126/min. What is the next best step in the management of this patient?
(A) Furosemide
(B) Diltiazem
(C) Transesophageal echocardiogram
(D) Start coumadin
(E) Mitral valvotomy
(F) Electrical cardioversion

Patient is hemodynamically stable. AF with Congestive heart failure. So to consider rate control, we use either of B -blockers, Calcium channel blockers, and Digoxin, AND warfarin

Ans: B

???
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Old 06-08-2012
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Here is the protocol for AF:


Hemodynamically Unstable (low BP, pt not responding to commands):

electric cardioversion



Hemodynamically Stable:

Acute = either cardioversion or rate control with meds

Chronic (> 48 hrs) = rate control with meds (diltiazem/metoprolol) + anticoagulation



This case would be B.
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Old 06-08-2012
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(B) Diltiazem
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Old 06-09-2012
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I would go first with furosemide to relieve his pul edema firstly then rate control with diltiazem. My Ans is A
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Old 06-09-2012
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Quote:
Originally Posted by bisho View Post
I would go first with furosemide to relieve his pul edema firstly then rate control with diltiazem. My Ans is A
the pumonary problems are due to the AF. Heart isn't pumping blood properly so its building up. Fix the AF and the rest of the problems will take care of themselves.
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