A 55-year-old African American woman presents to the ER with lethargy and blood pressure of 250/150. Her family members indicate that she was complaining of severe headache and visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On physical examination, retinal hemorrhages are present. Which of the following is the best approach?
Malignant hypertension occurs when diastolic blood pressure above 130 is associated with acute (or ongoing) target-organ damage. This patient shows evidence of damage, namely hypertensive encephalopathy (headache, visual disturbance, and altered mental status). Immediate therapy with nitroprusside in the ICU setting is indicated, although renal insufficiency would be a contraindication. Other options include intravenous nitroglycerin, fenoldopam, or enalapril. Intravenous labetalol is often used in hypertensive urgencies but, as a nonselective beta-blocker, is relatively contraindicated in asthma. An oral medication such as clonidine would be slow-acting and difficult to administer in a lethargic patient. Sublingual nifedipine is no longer advised because of increased potential for overshoot hypotension with adverse cardiovascular events such as MI, stroke, or ischemic optic neuropathy. Loop diuretics do not lower blood pressure rapidly.
An 18-year-old man complains of fever and transient pain in both knees and elbows. The right knee was red and swollen for 1 day during the week prior to presentation. On physical examination, the patient has a low-grade fever. He has a III/VI, high-pitched, apical systolic murmur with radiation to the axilla, as well as a soft, mid-diastolic murmur heard at the base. A tender nodule is palpated over an extensor tendon of the hand. There are pink erythematous lesions over the abdomen, some with central clearing. The following laboratory values are obtained:
The patient’s ECG is shown below.
Which of the following tests is most critical to diagnosis?
This 18-year-old presents with features of rheumatic fever. Rheumatic fever is diagnosed according to the Jones criteria. Evidence of recent streptococcal infection plus two major manifestations or one major and two minor manifestations satisfy the Jones criteria for diagnosis of acute rheumatic fever. Major criteria include carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules. Minor manifestations include fever, polyarthralgia, elevated erythrocyte sedimentation rate, and PR prolongation on ECG. This patient’s clinical manifestations include arthritis, fever, and murmur (consistent with mitral regurgitation). The rash suggests erythema marginatum, and a subcutaneous nodule is noted. Rheumatic subcutaneous nodules are pea sized and usually overlie extensor tendons. The rash is usually pink with clear centers and serpiginous margins. Laboratory data include an elevated erythrocyte sedimentation rate. The ECG shows evidence of first-degree AV block. An antistreptolysin O antibody is necessary to document prior streptococcal infection. Endocarditis (for which blood cultures and an echocardio-gram would be ordered) might cause fever, joint symptoms, and the tender nodule but would not account for the diastolic murmur or the characteristic skin lesion. There is no evidence of lupus or myocardial infarction.
A 36-year-old man presents with the sensation of a racing heart. His blood pressure is 110/70, respiratory rate 14/minute, and O 2 saturation 98%. His ECG shows a narrow QRS complex tachycardia with rate 180, which you correctly diagnose as paroxysmal atrial tachycardia. Carotid massage and Valsalva maneuver do not improve the heart rate. Which of the following is the initial therapy of choice?
Adenosine, with its excellent safety profile and extremely short half-life, is the drug of choice for supraventricular tachycardia. The initial dose is 6 mg. A dose of 12 mg can be given a few minutes later if necessary. Verapamil is the next alternative; if the initial dose of 2.5 to 5 mg does not yield conversion, one or two additional boluses 10 minutes apart can be used. Diltiazem and digoxin may be useful in rate control and conversion, but have a slower onset of action. Electrical cardioversion is reserved for hemodynamically unstable patients. Lidocaine is useful in ventricular (not supraventricular) arrhythmias.
A patient has been in the coronary care unit for the past 24 hours with an acute anterior myocardial infarction. He develops the abnormal rhythm shown below, although blood pressure remains stable at 110/68.
Which of the following is the best next step in therapy?
The ECG shows complete heart block. Although at first glance the P waves and QRS complexes may appear related, on closer inspection they are completely independent of each other (ie, dissociated). Complete heart block in the setting of acute myocardial infarction requires temporary (and often permanent) transvenous pacemaker placement. Atropine may be used as a temporizing measure. You would certainly want to avoid digoxin, beta-blockers, or any other medication that promotes bradycardia. There is no indication on this strip for cardioversion such as for atrial fibrillation/flutter or ventricular tachycardia/fibrillation. Lidocaine is contraindicated because it might suppress the ventricular pacemaker, leading to asystole.
A 70-year-old man with a history of coronary artery disease presents to the emergency department with 2 hours of substernal chest pressure, diaphoresis, and nausea. He reports difficulty “catching his breath.” An electrocardiogram shows septal T-wave inversion. The patient is given 325-mg aspirin and sublingual nitroglycerin while awaiting the results of his blood work. His troponin I is 0.65 ng/mL (normal < 0.04 ng/mL). The physician in the emergency department starts the patient on low-molecular-weight heparin. His pain is 3/10. Blood pressure is currently 154/78 and heart rate is 72. You are asked to assume care of this patient. What is the best next step in management?
The patient’s history suggests acute coronary syndrome (ACS). The combination of elevated troponin and lack of ST segment elevation on ECG is most consistent with non–ST elevation myocardial infarction (NSTEMI). Initial therapy for acute coronary syndrome includes aspirin, nitroglycerin, anticoagulation, and morphine. A cardioselective beta-blocker, such as metoprolol, is frequently given in the immediate management of ACS to decrease myocardial oxygen demand, limit infarct size, reduce pain, and decrease the risk of ventricular arrhythmias. Elevated blood pressure also increases myocardial oxygen demand. Given this patient’s increased blood pressure and continued pain, administration of a beta-blocker is the appropriate next step in his management. Administration of intravenous morphine would also be appropriate. Cardiac catheterization may well be necessary at some point during his evaluation, but there is no mortality benefit for emergent catheterization in NSTEMI. There is no role for thrombolytic therapy in patients with ACS without ST segment elevation. All patients with ACS should be admitted to a monitored cardiac unit with serial cardiac biomarkers to estimate the extent of cardiac damage, but the patient’s continued pain demands urgent treatment, not just further observation. Clopidogrel therapy is indicated for patients with ACS who will not be undergoing immediate coronary artery bypass grafting. Clopidogrel therapy, however, will not improve this patient’s elevated blood pressure nor decrease myocardial oxygen demand. The correct dose of clopidogrel is a loading dose of 300 to 600 mg, then 75 mg po daily.
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