R*Q
发帖数: 179 | 1 去年的考题, 大家体会一下感觉吧.
时限 30分钟: 20分钟准备, 10分钟口试答题.
Patient is a 68 year old female, very nice and pleasant, obese Caucasian
female with a past medical history of multiple medical problems. She was
unable to sleep last night because she could not catch her breath. Her son
brought her to the emergency room. Patient is still feeling short of breath
. She denies any acute chest pain at this point. She denies any recent
fever, chills, cough, or purulent sputum. All her prior records were
reviewed. She denies any recent fall, trauma, seizure-like activity. No
history of any recent diarrhea or dysuria. She denies any significant
weight gain or weight loss recently except for increasing edema in both legs
.
Past Medical History:
1. Diabetes Type II
2. Hypertension
3. Congestive Heart Failure
4. Hyperlipidemia
5. Obesity
Allergies:
Lisinopril (cough)
Vaccine history:
Patient recalls getting seasonal flu vaccine in October of last year; last
tetanus vaccine was 3 years ago. She received all her childhood vaccines.
Medications: (home medication list from local retail pharmacy)
1. Metoprolol tartrate 50mg daily
2. Furosemide 20mg daily
3. Pioglitazone 15mg daily
4. Zocor 20mg daily
5. Lantus 10 units subq at bedtime
Social History:
She denies any history of recent smoking, drinking, or drug abuse.
Vitals: Blood pressure 165/95mm/Hg, heart rate 98bpm, respiratory rate 18rpm
, temp 98.7°F
Labs:
Na 135, K 3.8, BUN 24, SrCr 1.7, gluc 145, hgb 12.8, hct 30.2, wbc 9.8, plt
219, BNP 600. 6 weeks ago her A1C was 7.2%
4 days later: Patient was treated adequately for an acute exacerbation of
congestive heart failure. Her edema has resolved. Before discharge an ECHO
reveals an EF of 34%. All labs have remained the same except BNP has
dropped to 42. Please complete a discharge assessment and plan for this
patient. |
c****m
发帖数: 626 | 2 抛砖引玉吧，我也好久没有复习cardiovascular 了。
下面是我的思路：
BUN 24 elevated (8-20)
Scr 1.7 elevated (Females: 0.6-1.0 mg/dl )
BUN/Scr=14.1 (OK)
Glucose 145 elevated (73-115)
hct 30.2 decreased (37%-47%)
BNP 600>500
A1C is slightly elevated
EF of 34%.
BNP 42
Medications: (home medication list from local retail pharmacy)
1. Metoprolol tartrate 50mg daily (beta blocker)
2. Furosemide 20mg daily (Loop diuretics)
3. Pioglitazone 15mg daily(for diabetes)
4. Zocor 20mg daily (simvastatin)
5. Lantus 10 units subq at bedtime (for diabetes)
coughing is a common side effect of lisinopril, not real allergy.
blood pressure is high
Assessment and Plan: (I need to know patient's weight to calculate CrCl.
Patient's dosage may be adjusted based on CrCl.)
1. First problem is heartfailure. Patient has stage C heart failure. BNP is
now normal. EF of 34% is low.
start 25 mg captopril TID (Monitoring: looking for signs of hypotension (
dizziness, weakness).
If within 1 week, those 3 not present (scr increase, serum K > 5.5, Sxmatic
hypotension), then we can slowly titrate over 2-3 weeks to treatment doses
of ACEI. Keep going until you get to these doses. If dry cough appears, add
dextromethorphan to control cough)
Furosemide 20mg daily
Metoprolol tartrate 50mg daily (Monitor for hypotension, bradycardia, fluid
retention, worsening HF, Decrease dose if Heart rate <50 beats/min)
2. Second problem is diabetes. Serum glucose is high. A1C level is high.
stop actos. Initiate metformin (need titration) Continue Lantus 10 units
subq at bedtime (for diabetes) Need Monitor blood glucose.
3. need lipid panel to assess the dosage of Zocor
4. Patient education on life style changes. Weight management, increase
exercise. |
b**o
发帖数: 5769 | 3 A and P.
【在 c****m 的大作中提到】
: 抛砖引玉吧，我也好久没有复习cardiovascular 了。
: 下面是我的思路：
: BUN 24 elevated (8-20)
: Scr 1.7 elevated (Females: 0.6-1.0 mg/dl )
: BUN/Scr=14.1 (OK)
: Glucose 145 elevated (73-115)
: hct 30.2 decreased (37%-47%)
: BNP 600>500
: A1C is slightly elevated
: EF of 34%.
|
b**o
发帖数: 5769 | 4 BNP是什麼？我們還沒學到Echo具體的東西。不過我會看出要換hypertension med.
glucose is still not at goal so maybe adjust insuline dose?
Since she has CHF now, beta blocker wouldn't be good choice. She need a
hypertension med that will benefit CHF and won't mask hyperglycemia?
Just my guess, we just started cardio and still on basic stuff now. |
P*******D
发帖数: 523 | 5 及时雨啊，不胜感激
son
breath
【在 R*Q 的大作中提到】
: 去年的考题, 大家体会一下感觉吧.
: 时限 30分钟: 20分钟准备, 10分钟口试答题.
: Patient is a 68 year old female, very nice and pleasant, obese Caucasian
: female with a past medical history of multiple medical problems. She was
: unable to sleep last night because she could not catch her breath. Her son
: brought her to the emergency room. Patient is still feeling short of breath
: . She denies any acute chest pain at this point. She denies any recent
: fever, chills, cough, or purulent sputum. All her prior records were
: reviewed. She denies any recent fall, trauma, seizure-like activity. No
: history of any recent diarrhea or dysuria. She denies any significant
|
f****o
发帖数: 2770 | 6 CHF:
metoprolol tartrate is NOT apporved for CHF.
Change to Toprol XL (metoprolol succinate) 100mg QD or 50mg BID. or Coreg
If she can't tolerate ACEI, she needs to be on ARB for CHF. ARB approved for
CHF: Diovan, Atacand.
metoformin contraindicated in her SCr level不能用的
DM, Lipid全部refer to PCP
hospital只负责acute heart failure exacerbation |
P*******D
发帖数: 523 | 7 补充一点。
Pioglitazone can cause CHF exacerbation. Might consider discontinuing it and
start another oral med since her A1C is not that bad. I also wonder if she
has AF with a HR of 98. But we don't have the number after she was treated.
Hopefully metoprolol can take care of some of that. I would follow up with
an EKG, if she does have, she might need an anticoagulant due to her CHADS2
score being high.
I would also recommend getting flu vaccine and pneumococcal vaccine for her. |
f****o
发帖数: 2770 | 8 good catch on Actos, contraindicated in NYHA Class III & IV,
and the vaccines.
and
her.
【在 P*******D 的大作中提到】
: 补充一点。
: Pioglitazone can cause CHF exacerbation. Might consider discontinuing it and
: start another oral med since her A1C is not that bad. I also wonder if she
: has AF with a HR of 98. But we don't have the number after she was treated.
: Hopefully metoprolol can take care of some of that. I would follow up with
: an EKG, if she does have, she might need an anticoagulant due to her CHADS2
: score being high.
: I would also recommend getting flu vaccine and pneumococcal vaccine for her.
|
w******e
发帖数: 42 | 9 start 25 mg captopril TID (Monitoring: looking for signs of hypotension (
dizziness, weakness).
Why you want to challenge the patient?
metoprolol tartrate is NOT apporved for CHF.
You are right about it. But in reality, some cardiologists do not care...
Since she has CHF now, beta blocker wouldn't be good choice.
Please refer the COMET trial.
she might need an anticoagulant due to her CHADS2 score being high.
Usually you do not need anticoagulation if pt do not have Afib and HF.
Please refer Warcef trial.
I would also consider to increase Lasix dose. |
w******e
发帖数: 42 | 10 Btw, everyone is OK with obesity? lol
Her A1c is not very high...I would encourage her to lose some weight...so
her DM will be well controlled without adding any new medication. |
|
|
b******8
发帖数: 1251 | 11 呵呵，课间10分钟，正在上HF的课：
第一个看到的就是，use ARB if intolerating ACE-i
2， should be metoprolol succinate, beta-blocker is fine when she is stable,
really stable.
3楼上的，你提的那些trails呀，我们老师要我们背呀，哪个trial证明了什么，我的天
呀，我保证我考完了马上忘。 |
l******k
发帖数: 27533 | 12 我们老师倒是觉得metformin is so good that it can be used at a low dose for
renal impaired patients.
metformin can not be used for this patient due to its contraindication to
heart failure.
for
【在 f****o 的大作中提到】
: CHF:
: metoprolol tartrate is NOT apporved for CHF.
: Change to Toprol XL (metoprolol succinate) 100mg QD or 50mg BID. or Coreg
: If she can't tolerate ACEI, she needs to be on ARB for CHF. ARB approved for
: CHF: Diovan, Atacand.
: metoformin contraindicated in her SCr level不能用的
: DM, Lipid全部refer to PCP
: hospital只负责acute heart failure exacerbation
|
l******k
发帖数: 27533 | 13 Good one!
Also the weight gain,edema and dislipidemia risks from pioglitazone.
and
she
.
CHADS2
her.
【在 P*******D 的大作中提到】
: 补充一点。
: Pioglitazone can cause CHF exacerbation. Might consider discontinuing it and
: start another oral med since her A1C is not that bad. I also wonder if she
: has AF with a HR of 98. But we don't have the number after she was treated.
: Hopefully metoprolol can take care of some of that. I would follow up with
: an EKG, if she does have, she might need an anticoagulant due to her CHADS2
: score being high.
: I would also recommend getting flu vaccine and pneumococcal vaccine for her.
|
l******k
发帖数: 27533 | 14 I agree that her A1C is not bad.
There's no evidence of the A1C goal for the elderly. A1C<8% is not bad.
However, Actos has to be changed to sulfonylureas or other oral diabetic
meds.
【在 w******e 的大作中提到】
: Btw, everyone is OK with obesity? lol
: Her A1c is not very high...I would encourage her to lose some weight...so
: her DM will be well controlled without adding any new medication.
|
P*******D
发帖数: 523 | 15 Please read the question more carefully.
4 days later: Patient was treated adequately for an acute exacerbation of
congestive heart failure. Her edema has resolved. Before discharge an ECHO
reveals an EF of 34%. All labs have remained the same except BNP has
dropped to 42. Please complete a discharge assessment and plan for this
patient.
About the HR, at first I thought the question means there was also no change
in HR after the treatment. After I read it over again, I found it could
mean that all labs remained the same but not necessarily the vitals. I would
ask for clarification if I were asked to present the case. |
l******k
发帖数: 27533 | 16 well, life style change should be tried before the initiation of Zocor:)
It's obvious that LSC didn't help her losing weight.
However, it is important to include LSC in the education part...
【在 w******e 的大作中提到】
: Btw, everyone is OK with obesity? lol
: Her A1c is not very high...I would encourage her to lose some weight...so
: her DM will be well controlled without adding any new medication.
|
l******k
发帖数: 27533 | 17 I think the question means the patient is pretty stable after the treatment.
The discharge plan focuses on using the beta blocker with CHF indication and
titrating it up according to HR.
ARB will be added for CHF and uncontrolled high blood pressure.
ECHO
change
would
【在 P*******D 的大作中提到】
: Please read the question more carefully.
: 4 days later: Patient was treated adequately for an acute exacerbation of
: congestive heart failure. Her edema has resolved. Before discharge an ECHO
: reveals an EF of 34%. All labs have remained the same except BNP has
: dropped to 42. Please complete a discharge assessment and plan for this
: patient.
: About the HR, at first I thought the question means there was also no change
: in HR after the treatment. After I read it over again, I found it could
: mean that all labs remained the same but not necessarily the vitals. I would
: ask for clarification if I were asked to present the case.
|
l******k
发帖数: 27533 | 18 亲～
我申请的好多program被拒的拒，没信儿的没信儿
心急如焚呀～～～
ECHO
change
would
【在 P*******D 的大作中提到】
: Please read the question more carefully.
: 4 days later: Patient was treated adequately for an acute exacerbation of
: congestive heart failure. Her edema has resolved. Before discharge an ECHO
: reveals an EF of 34%. All labs have remained the same except BNP has
: dropped to 42. Please complete a discharge assessment and plan for this
: patient.
: About the HR, at first I thought the question means there was also no change
: in HR after the treatment. After I read it over again, I found it could
: mean that all labs remained the same but not necessarily the vitals. I would
: ask for clarification if I were asked to present the case.
|
P*******D
发帖数: 523 | 19 Exactly! There were confusions on patient's condition and what we are asked
to do.
treatment.
and
【在 l******k 的大作中提到】
: I think the question means the patient is pretty stable after the treatment.
: The discharge plan focuses on using the beta blocker with CHF indication and
: titrating it up according to HR.
: ARB will be added for CHF and uncontrolled high blood pressure.
:
: ECHO
: change
: would
|
P*******D
发帖数: 523 | 20 我也是有一阵没有接到邀请了。希望再来一阵invites，我才有点信心啊。 据说这个长
周末有些program在review材料，希望咱们能再拿几个invites。 今年申请的人很多，
大家收到的invites都没往常多，给分薄了。
【在 l******k 的大作中提到】
: 亲～
: 我申请的好多program被拒的拒，没信儿的没信儿
: 心急如焚呀～～～
:
: ECHO
: change
: would
|
|
|
l******k
发帖数: 27533 | 21 知道了vital后discharge plan有什么改变吗？
asked
【在 P*******D 的大作中提到】
: Exactly! There were confusions on patient's condition and what we are asked
: to do.
:
: treatment.
: and
|
l******k
发帖数: 27533 | 22 我这阵子倒是接连收到拒信
就快受不了了
再收更多我得打电话给你了：（（（
我们怎么这么倒霉呀，真是赶上这“场子”了，我也听说今年申请的人巨多！
【在 P*******D 的大作中提到】
: 我也是有一阵没有接到邀请了。希望再来一阵invites，我才有点信心啊。 据说这个长
: 周末有些program在review材料，希望咱们能再拿几个invites。 今年申请的人很多，
: 大家收到的invites都没往常多，给分薄了。
|
c****m
发帖数: 626 | 23 谢谢指教，我还需要继续修行，呵呵
for
【在 f****o 的大作中提到】
: CHF:
: metoprolol tartrate is NOT apporved for CHF.
: Change to Toprol XL (metoprolol succinate) 100mg QD or 50mg BID. or Coreg
: If she can't tolerate ACEI, she needs to be on ARB for CHF. ARB approved for
: CHF: Diovan, Atacand.
: metoformin contraindicated in her SCr level不能用的
: DM, Lipid全部refer to PCP
: hospital只负责acute heart failure exacerbation
|
c****m
发帖数: 626 | 24 好事多磨啊，师姐加油
【在 l******k 的大作中提到】
: 我这阵子倒是接连收到拒信
: 就快受不了了
: 再收更多我得打电话给你了：（（（
: 我们怎么这么倒霉呀，真是赶上这“场子”了，我也听说今年申请的人巨多！
|
m**s
发帖数: 520 | 25 既然是充血性心力衰竭，就再下点保钾利尿剂螺内酯，外加点地高辛鉴于心跳得那么快。
ARB肯定是要用的如果ACEI不能上。餐前胰岛素也可以给if needed,因为上面的2个口服
降血糖都需要撤下来，不能用。
医院的医生都是这样吗？这么说药剂师还是很重要哦 |
a*****8
发帖数: 2115 | 26 Pt is also qualify for pneumococcal vaccine, she is over 65 and vaccine hx
did not show that she had gotten it before. |
a*****8
发帖数: 2115 | 27 BNP: brain naturiuretic peptide. It is released when atrium wall is streched
which mean patient is volume over load. If right atrium is over streched,
that mean BP or volume status through vena cava is high. In that case,
patient is peripheral volume overloaded. If left atrium is over streched,
that mean BP or volume status through pulmonary vein. In that case,lung is
congested. Either way, patient is volume overloaded and is in acute HF
exacerbation.
【在 b**o 的大作中提到】
: BNP是什麼？我們還沒學到Echo具體的東西。不過我會看出要換hypertension med.
: glucose is still not at goal so maybe adjust insuline dose?
: Since she has CHF now, beta blocker wouldn't be good choice. She need a
: hypertension med that will benefit CHF and won't mask hyperglycemia?
: Just my guess, we just started cardio and still on basic stuff now.
|
a*****8
发帖数: 2115 | 28 totally agreed. Well said.
HF is not an indication for anticoagulation. However, depend on what side of
HF, pt might have some underlying disease that need to be address.
【在 w******e 的大作中提到】
: start 25 mg captopril TID (Monitoring: looking for signs of hypotension (
: dizziness, weakness).
: Why you want to challenge the patient?
: metoprolol tartrate is NOT apporved for CHF.
: You are right about it. But in reality, some cardiologists do not care...
: Since she has CHF now, beta blocker wouldn't be good choice.
: Please refer the COMET trial.
: she might need an anticoagulant due to her CHADS2 score being high.
: Usually you do not need anticoagulation if pt do not have Afib and HF.
: Please refer Warcef trial.
|
P*******D
发帖数: 523 | 29 I agree. I was actually suspecting her having an active AF since at first I
thought her HR remained at 98 after appropriate treatment. I suggested
getting an EKG. If she does have AF, then anticoagulate her, if she doesn't,
then there is no such need.
of
【在 a*****8 的大作中提到】
: totally agreed. Well said.
: HF is not an indication for anticoagulation. However, depend on what side of
: HF, pt might have some underlying disease that need to be address.
|
w******e
发帖数: 42 | 30 Agree. Bcs EF<40, digoxin could be added.
快。
【在 m**s 的大作中提到】
: 既然是充血性心力衰竭，就再下点保钾利尿剂螺内酯，外加点地高辛鉴于心跳得那么快。
: ARB肯定是要用的如果ACEI不能上。餐前胰岛素也可以给if needed,因为上面的2个口服
: 降血糖都需要撤下来，不能用。
: 医院的医生都是这样吗？这么说药剂师还是很重要哦
|
|
|
R*Q
发帖数: 179 | 31 ANSWER KEY
Assessment at Time of Discharge:
1. Congestive heart failure core medications
2. Uncontrolled Hypertension
3. Diabetes management optimization
4. Vaccinations
Plan for Discharge:
1. Congestive Heart Failure
• Dose too low – metoprolol tartrate 50mg daily. Metoprolol
tartrate should be doses twice daily. It is used first line for CHF
patients so it is important to continue at discharge once CHF exacerbation
has resolved. Recommend to increase metoprolol tartrate dose to 50mg BID or
metoprolol 100mg XL daily. (metoprolol XL, bisoprolol, and carvedilol are
the only well studied and recommended beta blockers in CHF although we
commonly use metoprolol tartrate)
• Additional drug therapy needed – ACE/ARB. Due to EF ≤40% and
ACE/ARB is recommended to be added to therapy. Because of patient’s
allergy to ACE inhibitors, recommend low dose ARB such as losartan 25mg
daily. (any low dose ARB is can be considered a reasonable answer)
• Due to multiple risk factors it would be appropriate to recommend
starting a form of aspirin daily
2. Uncontrolled Hypertension
• Goal blood pressure for diabetic patient = 140/90. Titrate
additions of Metoprolol 50mg BID (or Metoprolol 100mg XL daily) and low dose
ARB to maintain a blood pressure of ≤ 130/80mmHg. (reasonable to consider
adding spironolactone or hydralazine if the previous two medications are not
enough to get blood pressure within goal range)
3. Diabetes Management Optimization
• Adverse drug reaction – pioglitazone. Pioglitazone is
contraindicated in patients with CHF due to the risk of an exacerbation due
to fluid retention. Recommend to stop pioglitazone and optimize diabetes
with other agents.
• HgA1c goal of <7% (patient is at 7.2). Recommend titrating Lantus
dose up to reach A1c goal. A1c should be rechecked every 3 months until at
goal. (It may be reasonable to recommend the addition of a sulfonylurea.
Metformin is not a good choice for this patient due to increased SrCr)
4. Vaccines
• Due to patient’s diabetes and CHF, she is a candidate for both
the flu and pneumococcal vaccines. She should be immunized before
discharged. Due to her age she only needs one pneumococcal vaccine. She
should be vaccinated for the flu yearly.
5. Other Reasonable Recommendations:
• Patient is obese and has hyperlipidemia: Patient should be placed
on a cardiac (low salt) and diabetic diets, get regular exercise, and
maintain lifestyle changes to lose weight. Patient should restrict fluids to
< 2 liters/day
• Lipid panel should be obtained: if lipids are not within goal
could add Tricor or gemfibrozil.
Goals for safety: Patient should be on optimal medications to manage blood
pressure, congestive heart failure, diabetes, and lipids. This will help
reduce the risk of future CHF exacerbations, stroke, and other illness that
could develop from these conditions.
Goals for efficacy: BP should be maintained at a goal of 130/80mmHg, pre-
prandial blood glucose 80-120mg/dl, post-prandial blood glucose 80mg/dl,
HgA1c < 7% goal, total cholesterol < 200mg/dl, LDL < 100mg/dl (due to
diabetes), HDL > 40mg/dl, and triglycerides <150mg/dl
Monitoring: Patient should continue to monitor their weight daily, blood
pressure on a regular basis, blood glucose AC and HS twice a day (rotate
time of day to watch for trends)
Education: Educate patient on new medications that were added to their
medication lists, remind them to stop medications that were stopped during
their hospital stay (such as pioglitazone)
Follow-up: Follow up with PCP and/or cardiologist with 4 weeks (no real
guidelines on what follow-up time would be. We are looking for the plan of
follow up so any appropriate range and explanation would be appropriate) |
f****o
发帖数: 2770 | 32 i don't agree with the answer key... |
R*Q
发帖数: 179 | |
f****o
发帖数: 2770 | |
R*Q
发帖数: 179 | 35 Residents of that year wrote them. Test of their skill/knowleadge too...
Preceptors provided guidence and reviewed the case afterword. |
l******k
发帖数: 27533 | 36 请问括号里的内容需要考的时候也写出来吗？
【在 R*Q 的大作中提到】
: ANSWER KEY
: Assessment at Time of Discharge:
: 1. Congestive heart failure core medications
: 2. Uncontrolled Hypertension
: 3. Diabetes management optimization
: 4. Vaccinations
: Plan for Discharge:
: 1. Congestive Heart Failure
: • Dose too low – metoprolol tartrate 50mg daily. Metoprolol
: tartrate should be doses twice daily. It is used first line for CHF
|
l******k
发帖数: 27533 | 37 对了，谢谢你帮大家练习准备
我要面试出来还活着，也跟大家分享经验，不管是成功还是失败，哈哈
你这穿着公用马甲，也没发版面奖励个包子啥的，只好干巴巴的说声谢谢了
【在 R*Q 的大作中提到】
: ANSWER KEY
: Assessment at Time of Discharge:
: 1. Congestive heart failure core medications
: 2. Uncontrolled Hypertension
: 3. Diabetes management optimization
: 4. Vaccinations
: Plan for Discharge:
: 1. Congestive Heart Failure
: • Dose too low – metoprolol tartrate 50mg daily. Metoprolol
: tartrate should be doses twice daily. It is used first line for CHF
|
R*Q
发帖数: 179 | 38 不好意思, 忘记说明了, 写出来不算, 讲出来才算.
【在 l******k 的大作中提到】
: 请问括号里的内容需要考的时候也写出来吗？
|
R*Q
发帖数: 179 | 39 版主不用客气, 发贴不是为了赚包子. 分享些资料,希望有所帮助.
【在 l******k 的大作中提到】
: 对了，谢谢你帮大家练习准备
: 我要面试出来还活着，也跟大家分享经验，不管是成功还是失败，哈哈
: 你这穿着公用马甲，也没发版面奖励个包子啥的，只好干巴巴的说声谢谢了
|
m**s
发帖数: 520 | 40 确实有帮助，多谢！
【在 R*Q 的大作中提到】
: 版主不用客气, 发贴不是为了赚包子. 分享些资料,希望有所帮助.
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w******3
发帖数: 36 | 41 啊？我希望你还只是个P1，或者是刚开始P2。。。你的这个Plan有很多问题啊
Edit：我看其他人也提出来了。。。我就不多说了
【在 c****m 的大作中提到】
: 抛砖引玉吧，我也好久没有复习cardiovascular 了。
: 下面是我的思路：
: BUN 24 elevated (8-20)
: Scr 1.7 elevated (Females: 0.6-1.0 mg/dl )
: BUN/Scr=14.1 (OK)
: Glucose 145 elevated (73-115)
: hct 30.2 decreased (37%-47%)
: BNP 600>500
: A1C is slightly elevated
: EF of 34%.
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l******k
发帖数: 27533 | 42 哈哈，是我忘记了，你开贴就说了是口试
【在 R*Q 的大作中提到】
: 不好意思, 忘记说明了, 写出来不算, 讲出来才算.
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l******k
发帖数: 27533 | 43 师妹当然是低年级的
有勇气和兴趣参与讨论我觉得非常好
就算说错了一点关系都没有，她还有好多时间和机会准备呢
【在 w******3 的大作中提到】
: 啊？我希望你还只是个P1，或者是刚开始P2。。。你的这个Plan有很多问题啊
: Edit：我看其他人也提出来了。。。我就不多说了
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a*****8
发帖数: 2115 | 44 I will have to disagree. Digoxin have no survival benefit and is not
considered as a frontline for HF. Not because EF<40, pt should be not dig.
If patient is well controlled with ACEI/ARB and BB, there is no need to add
digoxin. Even it is not controlled, next line should be spironolactone,
diuretics.
【在 w******e 的大作中提到】
: Agree. Bcs EF<40, digoxin could be added.
:
: 快。
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c****m
发帖数: 626 | 45 谢谢提醒，cardio 两年前学的，是需要复习了。
这个帖子里面学习了很多
【在 w******3 的大作中提到】
: 啊？我希望你还只是个P1，或者是刚开始P2。。。你的这个Plan有很多问题啊
: Edit：我看其他人也提出来了。。。我就不多说了
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w******e
发帖数: 42 | 46 写了半天 结果说我验证码过期了。。。
简单地说 你去看看guideline吧 在这种情况下使用digi的strength of evidence是B。
digi确实没有降低死亡率，但是有很多的临床试验证明digi能降低hospitalization
and symptoms.
add
【在 a*****8 的大作中提到】
: I will have to disagree. Digoxin have no survival benefit and is not
: considered as a frontline for HF. Not because EF<40, pt should be not dig.
: If patient is well controlled with ACEI/ARB and BB, there is no need to add
: digoxin. Even it is not controlled, next line should be spironolactone,
: diuretics.
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w******e
发帖数: 42 | 47 另外 我不同意使用spiro...
除非这个病人fail to response to loop, 你才可以加spiro...而且add spiro并没有
多少evidence
现在这个病人lasix计量是20mg daily，所以你首要的要考虑的是增加剂量。
答案里并没有关于利尿剂的剂量调整...考虑到病人complained increasing edema in
both legs，增加lasix计量是有必要的。
add
【在 a*****8 的大作中提到】
: I will have to disagree. Digoxin have no survival benefit and is not
: considered as a frontline for HF. Not because EF<40, pt should be not dig.
: If patient is well controlled with ACEI/ARB and BB, there is no need to add
: digoxin. Even it is not controlled, next line should be spironolactone,
: diuretics.
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r********r
发帖数: 352 | 48 I agree with ann2008 on this topic. Dig is not a first-line medication for
patient with heart failure. It doesn't have mortality benefit, has dangerous
side effects, and requires careful therapeutic monitoring. If the dig level
is above 0.8, it could produce worse outcome, and increase mortality. Not
that dig should bot be used in patient with heart failure. But I wouldn't
recommend it until all the standard therapy (BB/ACEI or ARB) are being
optimized. If a patient is already on target dose bb and ACEI/ARB, and
apropriate dose diuretics, and still have repeated exacerbation, it is not
wrong to add dig.
Before trying dig, I would agree to add spironolactone to standard therapy.
Aldosterone antagonists has both mortality and morbidity benefits as long as
the patient's renal function and K levels are not contraindicated to its
use (scr > 2.5, k > 5). It is actually a more popular medication being
prescribed for HF patients than dig. In practice, most patient I saw on dig
are for afib. Especially those patient with uncontrolled HF and symptomatic
a-fib.
lastly, loop diuretics doesn't produce mortality benefits either, it is
important for symptom control though. I agree with up titrate lasix dose, as
long as the patient's fluid status allows. |
b**o
发帖数: 5769 | 49 现在我知道这个题怎么做了！
He has : stage 2 hypertension
Since he has diabetes + CHF, BP goal should be <120/80mmHg
Beta Blocker need to be discontinued for her.
Reason not to use beta blocker:
bronchospasm – use is contraindicated in asthmatics and other lung diseases
heart failure (systolic dysfunction)
may mask insulin-induced hypoglycemia and delay recovery time ( more
pronounced with non-specific beta-blockers)
Her HR is OK though.
ACE -I is good drug for diabetes but since she has cough we can switch to
ARBs.
Reason not to use ACE: cough (she got this!), hyperkalemia (especially in
diabetics and those with renal insufficiency), elevated SCr.
Reason to use ARBs:
In hypertensive patients with microalbuminuria or clinical albuminuria, an
ACE inhibitor or an ARB should be strongly considered.
Need EKG and FLP.
Diabetes的药还不懂呢。 |
b**o
发帖数: 5769 | 50 今天我们还有Case讨论呢。不过主要针对hypertension。
就你这个case里面的hypertention用药，照我们老师教的用BB就很不合适，而且她还胸
闷，喘不过气来，这些应该都是BB的副作用引起的。
我们老师教的就是糖尿病，首选ACE and ARB，而且ARB还能减低尿蛋白，所以强力推荐
的是ARB.
还有diuretic首选是thiazid，不知道你这里用loop是不是主要因为她有CHF? 我们还没
有学到CHF呢。呵呵。
只能做一部分。
【在 R*Q 的大作中提到】
: Residents of that year wrote them. Test of their skill/knowleadge too...
: Preceptors provided guidence and reviewed the case afterword.
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l******k
发帖数: 27533 | 51 spironolactone 对stage III/IV HF证据挺明确的。It's very commonly used as
adjunctive therapy for HF
排在BB和ACEI之后
digoxin是last choice, and no evidence to improve mortality or morbidity
in
【在 w******e 的大作中提到】
: 另外 我不同意使用spiro...
: 除非这个病人fail to response to loop, 你才可以加spiro...而且add spiro并没有
: 多少evidence
: 现在这个病人lasix计量是20mg daily，所以你首要的要考虑的是增加剂量。
: 答案里并没有关于利尿剂的剂量调整...考虑到病人complained increasing edema in
: both legs，增加lasix计量是有必要的。
:
: add
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l******k
发帖数: 27533 | 52 胸闷，踹不过气是HF exacerbation symptoms
case没有病人有asthma的病历
看看HF的pathophysiology就知道为什么BB是首选必须用药了
【在 b**o 的大作中提到】
: 今天我们还有Case讨论呢。不过主要针对hypertension。
: 就你这个case里面的hypertention用药，照我们老师教的用BB就很不合适，而且她还胸
: 闷，喘不过气来，这些应该都是BB的副作用引起的。
: 我们老师教的就是糖尿病，首选ACE and ARB，而且ARB还能减低尿蛋白，所以强力推荐
: 的是ARB.
: 还有diuretic首选是thiazid，不知道你这里用loop是不是主要因为她有CHF? 我们还没
: 有学到CHF呢。呵呵。
: 只能做一部分。
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l******k
发帖数: 27533 | 53 nice review!
Thanks
dangerous
level
.
【在 r********r 的大作中提到】
: I agree with ann2008 on this topic. Dig is not a first-line medication for
: patient with heart failure. It doesn't have mortality benefit, has dangerous
: side effects, and requires careful therapeutic monitoring. If the dig level
: is above 0.8, it could produce worse outcome, and increase mortality. Not
: that dig should bot be used in patient with heart failure. But I wouldn't
: recommend it until all the standard therapy (BB/ACEI or ARB) are being
: optimized. If a patient is already on target dose bb and ACEI/ARB, and
: apropriate dose diuretics, and still have repeated exacerbation, it is not
: wrong to add dig.
: Before trying dig, I would agree to add spironolactone to standard therapy.
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a*****8
发帖数: 2115 | 54 Beta-blocker is not a contraindication in asthma or COPD patient. When
patient experienced acute asthma attack, do not initiate BBs or may hold BBs
during asthma attach. However, asthma or COPD are not a reason to withhold
BBs. Like Lilybank said 胸闷，喘不过气来 is due to pt is having an acute
heart failre exacerbation and probably very volume overloaded. It like he is
drowning and will cause 胸闷，喘不过气来. So diruetics especially loop
diuretics is very potent.
Also BB can mask hypoglycemia, however, again, it is not the reason to
withhold BB. You can monitor BG more frequently if you are concerned but in
this case BB should not be held and need to be titrated to max dose if pt
tolerated.
I might be wrong, I thought BP goal for DM is 130/80, not 120/80 though.
diseases
【在 b**o 的大作中提到】
: 现在我知道这个题怎么做了！
: He has : stage 2 hypertension
: Since he has diabetes + CHF, BP goal should be <120/80mmHg
: Beta Blocker need to be discontinued for her.
: Reason not to use beta blocker:
: bronchospasm – use is contraindicated in asthmatics and other lung diseases
: heart failure (systolic dysfunction)
: may mask insulin-induced hypoglycemia and delay recovery time ( more
: pronounced with non-specific beta-blockers)
: Her HR is OK though.
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w******e
发帖数: 42 | 55 Before the release of EMPHASIS-HF in 2011, the usage of spiro was limited to
current or recent NYHA class IV HF with LVEF ≤35 based on RALES trial, and
recent myocardial infarction with LVEF ≤40 plus symptomatic HF and/or
diabetes based on EPHESUS trial.
EMPHASIS-HF trial showed a 37% reduction in the primary end point of the
composite of death from cardiovascular causes or hospitalization for heart
failure, a 24% reduction in cardiovascular death, and a 42% reduction in
hospitalization for heart failure in patients with systolic heart failure
and mild symptoms. Remarkably, only 96 of 2737 patients were enrolled with
LVEF >30. EMPHASIS-HF trial supports treatment of selected patients with
NYHA class II HF and LVEF ≤30 percent and recent hospitalization for a
cardiovascular reason.
This case does not tell us the severity of patient's limitation of physical
activity, I assume it is NYHA class II -III. EF is 34%. You can give Spiro
to patients NYHA functional class III to IV HF and an LVEF ≤35%. But
personally I do not see a strong evidence to use Spiro in our case based on
the results of three trials above. I would be OK if Patient D/C without
Spiro.
dangerous
level
.
【在 r********r 的大作中提到】
: I agree with ann2008 on this topic. Dig is not a first-line medication for
: patient with heart failure. It doesn't have mortality benefit, has dangerous
: side effects, and requires careful therapeutic monitoring. If the dig level
: is above 0.8, it could produce worse outcome, and increase mortality. Not
: that dig should bot be used in patient with heart failure. But I wouldn't
: recommend it until all the standard therapy (BB/ACEI or ARB) are being
: optimized. If a patient is already on target dose bb and ACEI/ARB, and
: apropriate dose diuretics, and still have repeated exacerbation, it is not
: wrong to add dig.
: Before trying dig, I would agree to add spironolactone to standard therapy.
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w******e
发帖数: 42 | 56 In the discharge assessment, if you can give some suggestion in case of
worse of symptoms in the future, this will set you apart from other
candidates during the interview. That's why I mention digi.
I do not understand why both of you disagreed with me...I did not say: Digi
MUST be added...I never say digi is the primary therapy for the
stabilization of patients with acutely decompensated HF either...and both of
you agreed that Digi could be added if pt still has symptoms after standard
treatment.The case only stated "Patient was treated adequately for an acute
exacerbation of congestive heart failure. Her edema has resolved." We do
not know whether this pt still have symptoms or physical limitation.
let me make myself clear, my recommendation is digi can be used in patients
with left ventricular systolic dysfunction (LVEF <40) who continue to have
NYHA class II, III and IV symptoms despite optimal therapy. You can refer
DIG trial for more info.
BTW, It is worth pointing out that digoxin is NOT indicated for primary
stabilization of patients with an acute exacerbation of HF symptoms which
our pt has in this case.
dangerous
level
.
【在 r********r 的大作中提到】
: I agree with ann2008 on this topic. Dig is not a first-line medication for
: patient with heart failure. It doesn't have mortality benefit, has dangerous
: side effects, and requires careful therapeutic monitoring. If the dig level
: is above 0.8, it could produce worse outcome, and increase mortality. Not
: that dig should bot be used in patient with heart failure. But I wouldn't
: recommend it until all the standard therapy (BB/ACEI or ARB) are being
: optimized. If a patient is already on target dose bb and ACEI/ARB, and
: apropriate dose diuretics, and still have repeated exacerbation, it is not
: wrong to add dig.
: Before trying dig, I would agree to add spironolactone to standard therapy.
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l******k
发帖数: 27533 | 57 别急别急呀
我觉得我们说得差不多呀
dig当然能用，但我们觉得应该做为last resort
spironolactone先试，如果BB，ACEI和spir都不能很好的控制，再加dig
不过临床中，我倒经常看到连BB和ACEI都没同时上就很早的用dig了。dig在以前用得非
常广泛，用得早的病人就一直这样用下去了
非常同意你说的在写SOAP的时候，plan里加上alternative therapy or future plan
if the recommended therapy fail. Actually, it is required for our SOAP exam
in P2/P3 years.
Digi
of
standard
acute
【在 w******e 的大作中提到】
: In the discharge assessment, if you can give some suggestion in case of
: worse of symptoms in the future, this will set you apart from other
: candidates during the interview. That's why I mention digi.
: I do not understand why both of you disagreed with me...I did not say: Digi
: MUST be added...I never say digi is the primary therapy for the
: stabilization of patients with acutely decompensated HF either...and both of
: you agreed that Digi could be added if pt still has symptoms after standard
: treatment.The case only stated "Patient was treated adequately for an acute
: exacerbation of congestive heart failure. Her edema has resolved." We do
: not know whether this pt still have symptoms or physical limitation.
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a*****8
发帖数: 2115 | 58 You don't have to get upset about we are not agreeing with you. Based on
your comments" Agree. Bcs EF<40, digoxin could be added." My interpretation
at that point: dig is not my next line of therapy.I rather use aldostrone
inhibitor, even hydralazine/nitrate over dig. If you are asking for trials,
EMPHASIS-HF showed eplerenone extend patient population that could benefit
from a aldostrone inhibitor. From EPHESUS trial (post-MI), to EMPHASIS-HF (
mild HF) to RALES trial (severe HF), aldosterone inhibitor showed a great
mortality benefit in variety of patient where evidence did not showed
digoxin is superior over other treatment.
to
and
【在 w******e 的大作中提到】
: Before the release of EMPHASIS-HF in 2011, the usage of spiro was limited to
: current or recent NYHA class IV HF with LVEF ≤35 based on RALES trial, and
: recent myocardial infarction with LVEF ≤40 plus symptomatic HF and/or
: diabetes based on EPHESUS trial.
: EMPHASIS-HF trial showed a 37% reduction in the primary end point of the
: composite of death from cardiovascular causes or hospitalization for heart
: failure, a 24% reduction in cardiovascular death, and a 42% reduction in
: hospitalization for heart failure in patients with systolic heart failure
: and mild symptoms. Remarkably, only 96 of 2737 patients were enrolled with
: LVEF >30. EMPHASIS-HF trial supports treatment of selected patients with
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b**o
发帖数: 5769 | 59 oh!原来这样，先学着啦！我们下下周讲HF。
BP goal for diabetes (ADA 2013) is < 140/80
For CAD or high CAD risk (AHA 2007) is <130/80
HF (AHA 2007) is < 120/80
没有错的，她有HF呀。当然是 小于 120/80
BBs
withhold
is
in
【在 a*****8 的大作中提到】
: Beta-blocker is not a contraindication in asthma or COPD patient. When
: patient experienced acute asthma attack, do not initiate BBs or may hold BBs
: during asthma attach. However, asthma or COPD are not a reason to withhold
: BBs. Like Lilybank said 胸闷，喘不过气来 is due to pt is having an acute
: heart failre exacerbation and probably very volume overloaded. It like he is
: drowning and will cause 胸闷，喘不过气来. So diruetics especially loop
: diuretics is very potent.
: Also BB can mask hypoglycemia, however, again, it is not the reason to
: withhold BB. You can monitor BG more frequently if you are concerned but in
: this case BB should not be held and need to be titrated to max dose if pt
|
a*****8
发帖数: 2115 | 60 No you are right about the 120/80 goal, just I am not familiar with it.
【在 b**o 的大作中提到】
: oh!原来这样，先学着啦！我们下下周讲HF。
: BP goal for diabetes (ADA 2013) is < 140/80
: For CAD or high CAD risk (AHA 2007) is <130/80
: HF (AHA 2007) is < 120/80
: 没有错的，她有HF呀。当然是 小于 120/80
:
: BBs
: withhold
: is
: in
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w******e
发帖数: 42 | 61 Now I am upset...I already reviewed the EMPHASIS-HF trial and specifically
pointed out that "only 96 of 2737 patients were enrolled with LVEF >30". The
result of EMPHASIS-HF can not be applied to our pt in this case whose EF is
34.
Also I never say digoxin is superior over other treatment. Please do not
over-interpret my post.
I believe all the discussion should be based on clinical trials or
guidelines rather than personal opinion. This is evidence-based practice,
and this is how I make argument. Pharmacy students in this forum can take
advantage of our discussion and get familiar with those clinical trials.
I feel your disagreement of my post about digi is kind of misleading. Other
readers may think digi could not be used in this pt in any scenario. Since I
raised it, I have the responsibility to make it clear.
Disagreement is common is an argument；there was no reason for me to be
upset. Any post is welcome and appreciated as long as it makes sense.
interpretation
,
【在 a*****8 的大作中提到】
: You don't have to get upset about we are not agreeing with you. Based on
: your comments" Agree. Bcs EF<40, digoxin could be added." My interpretation
: at that point: dig is not my next line of therapy.I rather use aldostrone
: inhibitor, even hydralazine/nitrate over dig. If you are asking for trials,
: EMPHASIS-HF showed eplerenone extend patient population that could benefit
: from a aldostrone inhibitor. From EPHESUS trial (post-MI), to EMPHASIS-HF (
: mild HF) to RALES trial (severe HF), aldosterone inhibitor showed a great
: mortality benefit in variety of patient where evidence did not showed
: digoxin is superior over other treatment.
:
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b**o
发帖数: 5769 | 62 我们才上了HF!又说HF不能用metoprolol tartrate, 要用XL. |
r********r
发帖数: 352 | 63 不是不能，而是clinical study不是建立在 Lopressor 上的，而是 Toprol。 实际上
用lopressor的病人多去了。上课考试记住要用toprol就是了。嘿嘿
【在 b**o 的大作中提到】
: 我们才上了HF!又说HF不能用metoprolol tartrate, 要用XL.
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b******8
发帖数: 1251 | 64 就只能用三个呀，bisoprolol, metoprolol succinate, carvedilol,BEST trial说了
it's not a class indication for beta blocker.后天考HF/AF/dysrhythmias.我们居
然要背所有的trials |
l******k
发帖数: 27533 | 65 其实再想想，tartrate和succinate区别除了dosing不同，就是价格了
我觉得两种都可以的
临床上我见过医生劝买不起药的病人用tartrate，因为便宜，说是也同样work的
【在 b**o 的大作中提到】
: 我们才上了HF!又说HF不能用metoprolol tartrate, 要用XL.
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