Download BrainX Digital Learning System: Internal Medicine Board by Conrad Fischer PDF

By Conrad Fischer

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Extra resources for BrainX Digital Learning System: Internal Medicine Board Practice Exams (2003)

Sample text

When you are switching medications for treatment failure of the HIV, it is important to change at least two medications. This patient's medications are being changed because of drug toxicity. There is no point in starting a colony-stimulating factor because there are many alternatives to the use of zidovudine. Bone-marrow biopsy might be useful only if the zidovudine were stopped and the white cell count were to remain low in order to treat a primary marrow production problem. Lamivudine has virtually no adverse effects, so it is appropriate to continue it.

The irregularly irregular rhythm suggests atrial fibrillation. Because the patient is hemodynamically stable, the most important initial step is to lower the heart rate to less than 100/min. Electrical cardioversion is indicated when there is evidence of hemodynamic instability, such as hypotension, congestive heart failure, an altered mental status, or chest pain. Elective cardioversion could be undertaken after the rate is controlled but only after there has been anticoagulation for several weeks beforehand or a transesophageal echocardiogram has been performed.

Physical examination is significant for jugular venous distention (JVD) worsening on inspiration, an S3 gallop with 3/6 systolic murmur radiating to the axilla, bibasilar crackles, and 1+ lower extremity edema bilaterally. EKG shows atrial fibrillation at rate of 72 per minute. Pulmonary congestion and an enlarged heart size are seen on chest x-ray. Echocardiogram is significant for reduced left ventricular systolic function, an ejection fraction of 22%, and decreased myocardial wall thickness.

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