A 58 year old man comes to your clinic for regular follow up. He has a longstanding history of systolic heart failure with an estimated ejection fraction of 39%. At rest he is asymptomatic and feels fine. With limited activity such as walking to the bathroom or walking to the kitchen the patient gets very short of breath and endorses chest discomfort that increases dramatically with increasing activity intensity. He exhibits trace pedal edema and does not have audible crackles on exam. His JVP is not elevated.
Currently he is taking: Aspirin 81, lisinopril 40, carvedilol 12.5, furosemide 40mg daily
Vitals: BP 139/85, HR 87, RR 12 satting 99% on room air, temperature of 98.7
EKG reveals sinus rhythm with left axis deviation and q waves that are not new compared to prior. QRS interval is revealed to be 101ms
Labs reveal the following:
Hemoglobin 13.6
White blood cells 7.4k
Platelets 342k
Sodium 14
Potassium 3.6
Chloride 102
Bicarb 26
BUN 15
Creatinine 1.1
Glucose 97
Which of the following would be the most beneficial to the patient?
a) Add on digoxin 125mcg daily
b) Add on spironolactone 25mg daily
c) Add on losartan 100mg daily
d) Implanting a CRT device
e) Add on MS-Kadian 10g every 5 minutes
>>28241200
The patient appears to be suffering somewhat, so I would suggest 'e'. The will reduce pain substantially.
>tfw spent 15 minutes making up this question
>>28241200
i'm bigpharma, i own all these medicines and i will not allow you to use them on this man
>Sodium 14
He's already dead
Fuck this internal medicine shit.
Inject him with a lethal dose of morphine
>>28241200
All of the above. I'm a goddamn madman.
the usual doc. morphine, extra lethal
>>28241682
I meant it to be 140
At least you know I did not copy and paste this from some question bank
>>28241706
My last question was semi-surgical one
Are you a medfag, OP? I will be starting medical school this year. How do I maximize my Step 1 score?
glucose 96?
get him on some serious insulin
Aspirin 81? 81mg? I'm british but as far as i know its 75mg
I don't know about adding on anything to be honest out of those choices
digoxin maybe? although thats predominantly mono therapy
>>28241833
wait are you giving the glucose in mg/dL or mmol/l?
fucking mericans, use mmol/L like a reasonable medical professional
if it is mg/dL then 96 is fine for non diabetics
>>28241909
>>28241833
>doesn't know anything about medicine
>thinking he has a right to criticize people on US vs SI units
>>28241804
just do UWorld a bunch of times and you'll get a 240
>>28241200
Pharmfag guessing B based on furosemide + lisinopril and avoiding the potential for the potassium to drop too low. Also its right in the guidelines.
Pharmacy student who hasn't had cardiology yet, but searching on dynamed I found left axis deviation and QRS < 110 seem to point to LAFB, where I guess pacemaker is the only possible option. Don't recognize what any of that means other than the QRS interval, so good chance I'm wrong.
The one concern I can plainly see is uncontrolled hypertension on lisinopril, furosemide and carvedilol where I'd have to agree with >>28242904
>>28241200
If any of you are wondering what the real answer is its spironolactone. This patient has NYHA class three heart failure
>>28243184
It concerns me that there are real doctors right here now on /r9k/ laughing and making jokes about Harold Shipman
>>28241200
>Which of the following would be the most beneficial to the patient?
Lethal dose of morphine
>>28243206
They're the people who'd find him the most funny.
>>28243206
I figured if Harold was going to stick around, I may was well at least put some real medicine into it
