P-treatment

CASE STUDY

A 35-year-old man presents with a blood pressure of 150/95 mm Hg. He has been generally
healthy, is sedentary, drinks several cocktails per day, and does not smoke cigarettes. He has a

family history of hypertension, and his father died of a myocardial infarction at age 55. PhysicalA
35-year-old man presents with a blood pressure of 150/95 mm Hg. He has been generally
healthy, is sedentary, drinks several cocktails per day, and does not smoke cigarettes. He has a
family history of hypertension, and his father died of a myocardial infarction at age 55. Physical

examination is remarkable only for moderate obesity. Total cholesterol is 220 and high-density
lipoprotein (HDL) cholesterol level is 40 mg/dL. Fasting glucose is 105 mg/dL. Chest x-ray is
normal. Electrocardiogram shows left ventricular enlargement. How would you treat this
patient?

 CASE STUDY
A 74-year-old man presents with a history of anterior
chest pressure whenever he walks more than one
block. The chest discomfort is diffuse, and he cannot
localize it; sometimes it radiates to his lower jaw. The
discomfort is more severe when he walks after meals
but is relieved within 23 minutes when he stops
walking.
What medical treatments should be implemented to
reduce the acute pain of an attack, to prevent future
attacks, and to reduce the chance of blood clotting?

 CASE STUDY
A 50-year-old man has developed shortness of breath with exertion
several weeks after experiencing a viral illness. This is accompanied
by swelling of the feet and ankles and some increasing fatigue. On
physical examination he is found to be mildly short of breath lying
down, but feels better sitting upright. Pulse is 105 and regular, and
blood pressure is 90/60 mm Hg. His lungs show crackles at both
bases, and his jugular venous pressure is elevated. A third heart
sound is present but no murmurs are heard on auscultation of the
heart. The liver is enlarged, and there is 3+ edema of the ankles and
feet. An echocardiogram shows a dilated, poorly contracting heart
with a left ventricular ejection fraction of about 20% (normal: 60%).
Because of an abnormal ECG, he undergoes a coronary angiogram,
which shows normal coronary arteries.

 He is placed on a low-sodium diet and treated with a diuretic

(furosemide 40 mg twice daily) and digoxin 0.25 mg daily. On this
therapy, he is less short of breath on exertion and can also lie flat
without dyspnea. An angiotensin-converting enzyme (ACE) inhibitor
is added (enalapril 20 mg twice daily), and over the next few weeks
he continues to feel better. Three months after the first visit, the
man is asymptomatic at rest and with mild exercise. Heart rate is
80, and blood pressure is 110/70. A repeat echocardiogram shows
that his heart is smaller (though not back to normal) and his left
ventricular ejection fraction has improved to 40%. What other
pharmacologic options are available if this mans disease remains
stable?
What treatments are available if his heart failure suddenly becomes
worse?

 CASE STUDY
A 69-year-old retired teacher presents with a 1month history of palpitations, intermittent
shortness of breath, and fatigue. She has a
history of hypertension. An ECG shows atrial
fibrillation with a ventricular rate of 122 per
minute and signs of left ventricular hypertrophy.
She is anticoagulated with warfarin and started
on sustained-release metoprolol 50 mg/d. After 7
days, the patients rhythm reverts to normal sinus
spontaneously.

 However, over the ensuing month, she continues

to have intermittent palpitations and fatigue.
Continuous ECG recording over a 48-hour period
documents paroxysms of atrial fibrillation with
heart rates of 88114 bpm. An echocardiogram
shows a left ventricular ejection fraction of 38%
with no localized wall motion abnormality.
At this stage, would you initiate treatment with
an antiarrhythmic drug to maintain normal sinus
rhythm, and if so, what drug would you choose?

 CASE STUDY
A 25-year-old woman presents to the emergency
department complaining of acute onset of shortness of
breath and pleuritic pain. She had been in her usual
state of health until 2 days prior when she noted that
her left leg was swollen and red. Her only medication
was oral contraceptives. Family history was significant
for a history of blood clots in multiple members of
the maternal side of her family. Physical examination
demonstrates an anxious woman with stable vital
signs.

 The left lower extremity demonstrates erythema and

edema and is tender to touch. Ultrasound reveals a
deep vein thrombosis in the left lower extremity; chest
computed tomography scan confirms the presence of
pulmonary emboli.
What are the likely risk factors in this woman
hereditary, acquired, or both?
What therapy is indicated acutely?
What are the long-term therapy options?
How long should she be treated?
Should this individual use oral contraceptives?

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Contraceptive
Hormons