#491. A 65-year-old African-American male with a long-standing history of coronary artery disease and hypertension presents with shortness of breath and fatigue. Patient says he feels fatigued throughout the day and that he can no longer walk across the room without being short of breath. Patient states that symptoms onset a couple days ago and have steadily worsened.
Vitals are temperature 37 °C (98.6 °F), blood pressure 165/82 mm Hg, pulse 100/min, respirations 18/min, and oxygen saturation 97% on room air. On physical exam, patient appears alert and in no apparent distress. Cardiac exam reveals a load P2 and an S3 gallop. Pulses are regular but have alternating strong and weak beats. Mean jugular venous pressure is 12 cm H20. Pulmonary exam reveals crackles in the lower lung fields bilaterally. Extremities are cool to the touch and there is 2+ pitting edema bilaterally.
Laboratory tests show:
Sodium 120 mEq/L
Potassium 4.0 mEqL
Chloride 100 mEq/L
Bicarbonate 25 mEq/L
BUN 45 mg/dL
Creatinine 1.0 g mg/dL
Glucose (fasting) 90 mg/dL
Magnesium 1.7 mg/dL
Calcium 9.0 mg/dL
Phosphorous 4.1 mg/dL
Bilirubin, conjugated 0.2 mg/dL
Bilirubin, total 1.0 mg/dL
AST (SGOT) 20 mU/mL
ALT (SGPT) 15 mU/mL
Alkaline Phosphatase 80 U/L
WBC 7000 / mm3
RBC 5 x 106/mm3
Hematocrit 45%
Hemoglobin 15.0 g/dL
Platelet Count 250,000 / mm3
BNP 750 pg/mL
NT-proBNP 1250 pg/mL
Troponin T (cTnT) 0.05 ng/mL
Troponin I (cTnI) 0.03 ng/mL
Chest X-ray reveals evidence of pulmonary vascular congestion and pulmonary edema in the lung bases bilaterally. EKG reveals Q wavs in leads V1 and V2, evidence of left ventricular hypertrophy and a left bundle branch block. Transthoracic echocardiography reveals a LV ejection fraction of 25%, increased left ventricular wall thickness, moderate left atrial enlargement, and evidence of left anterior wall dyskinesis consistent with an old anterior wall myocardial infarction.
Patient is admitted to CCU and started on high flow 100% oxygen by nasal canula. Carvedilol 25 mg orally twice daily, captopril 25 mg orally three times daily, furosemide 100 mg orally, and eplerenone 25 mg orally daily are initiated.
Which of the following is the next best step in management of this patient
A. Administer 1 L NS bolus and then NS + 20 mEq/L KCL IV at 115 mL/h
B. Initiate hydralazine 35 mg orally 3 times daily and isosorbide dinitrate 20 mg orally 3 times daily.
C. Restrict sodium intake to 5 g/day
D. Initiate digoxin 4 mcg/kg orally daily
E. Initiate diltiazem 150 mg orally daily
@card-hageman
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