222 ) A 70-year-old white man with type 2 diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease and severe chronic obstructive pulmonary disease is admitted with increasing shortness of breath. The patient lives by himself and he has not been very compliant with his medications. On examination, he is awake and oriented, blood pressure is 230/140 . Funduscopic examination reveals papilledema. Chest exam reveals bilateral crepitations. Neurological examination is normal. An electrocardiogram reveals non specific ST segment changes. A chest x-ray shows bilateral pulmonary edema. Pulse oximetry reveals a saturation of 89% on room air. The patient is started on oxygen by nasal cannula. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 2.2mg%. Which of the following is the most appropriate next step in management?
A) Non-contrast CT Scan, head
B) Intravenous Sodium nitroprusside
C) Intravenous Labetalol
D) Fenoldapam
E) Cardiac catheterization.
Filed under: USMLE Test Prep | Tagged: Archer cardiology, Archer pulmonology, USMLE STEP 3 CARDIOLOGY, usmle step 3 critical care, USMLE STEP 3 PULMONOLOGY |
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D……
Funduscopic examination reveals papilledema….malignant hypertension
The most commonly used intravenous drug is nitroprusside. An alternative for patients with renal insufficiency is intravenous fenoldopam. Labetalol is another common alternative, providing easy transition from intravenous to oral dosing. However, a trial by Peacock et al demonstrated that intravenous calcium blockers (eg, nicardipine) could be useful in quickly and safely reducing blood pressure to target levels and seemed more effective than intravenous labetalol
Labetalol would be the safest choice in this case because there’s no renal contraindication to the use of IV labetolol. Moreover, Fenoldapam causes glaucoma and raises the intra ocular pressure. This patient already has papilledema!
What’s the answer ARCHER? Fenoldapam or IV labetolol
Severe COPD is an issue that limits the use of Labetalol. Answer is therefore, fenoldapam
Clicked dislike by mistake.like and thank you Archer.
D) Thank you Dr. Red