Assignment help needed

Patient has infective endocarditis and I can read the ECGs just fine, I know its basic but I need someone to help talk through the BPs with me.

Her BP before the loop diuretic is 170/60 which is obviously high and then after the diuretic its 150/30. The second ECG shows she has became bradycardic and hypokalaemic...the third ECG shows 3rd degree heart block. Does this link to her BP?

I understand how diuretics work and know the whole purpose of the diuretic was to reduce the BP. But why is her diastolic so low? Is this because of the lowered venous return or because of the aortic regurgitation or even the pulmonary oedema.

Please help, she's dying on me! :smile:

Semester-2-Assignment-2013-5595.pdf208.3KB

Reply 1

Helenia

Original post by jenni512

Or was it? :wink:

Acute use of a loop diuretic is not usually done to reduce BP. She has some important other symptoms which warranted the furosemide. Look up "causes of widened pulse pressure," which will hopefully help you understand why her BP was behaving that way.

Also look again at those ECGs - that 2nd one does not only show a bradycardia.

Reply 2

jenni512

Sorry yes I also meant to say that she has aortic regurgitation which is indicitive by the collapsing pulse, is this the reason for the furosemide to be given?

Reply 3

Helenia

Original post by jenni512

Sorry yes I also meant to say that she has aortic regurgitation which is indicitive by the collapsing pulse, is this the reason for the furosemide to be given?

She also has cool peripheries, widespread lung crackles and hypoxia...

Reply 4

jenni512

Ahhhh of course! I knew she had pulmonary oedema I just didnt link it all up. So she has left congestive heart failure thus the high systolic pressure and the treatment with Furosemide!

Thank you so much :smile:

Reply 5

Helenia

Original post by jenni512

Almost. She has a widened pulse pressure because she has AR due to endocarditis. Because this AR is presumably fairly new and of rapid onset, her LV is unable to keep up and so is failing, hence the pulmonary oedema. The furosemide is primarily to treat the pulmonary oedema. It may well have the side effect of lowering her blood pressure, but this is neither the primary aim nor necessarily desirable.

Reply 6

Kinkerz

This dialogue made me feel more enthusiastic about returning to medicine in August. I thank you.

Reply 7

Catchetat

My take...

First ECG is second degree (mobitz type 1 aka wenkebach) heart block. second is hypokalaemia (see the U wave). And as you've said, third degree heart block in figure 3. All to do with her falling potassium.

(edited 11 years ago)

Reply 8

Helenia

Original post by Catchetat

You don't have enough ECG to diagnose Wenckebach on the first one. The PR interval looks stable to me, and there are no dropped beats - so it's 1st degree block.

The 2nd one could be hypokalaemia with the "U waves" but there are no other convincing features of it on there (and with this being a fairly early med school assignment they'd usually give you more than that), and my feeling would be that it shows type II 2nd degree heart block with a 2:1 block. Complete heart block is a rare complication of hypokalaemia. You are also given no potassium readings so can't make too many assumptions about it, though it's a possibility. There's another reason why someone with aortic valve endocarditis might develop heart block though.

Reply 9

Isometrix

Original post by Kinkerz

This dialogue made me feel more enthusiastic about returning to medicine in August. I thank you.

It actually scared me with how much I've forgotten :woo:

Reply 10

Philosoraptor

Haven't looked at the ECG but was assuming acute LV dysfunction (with pulmonary oedema as a result) due to aortic regurgitation from infective endocarditis.

Now whether I'd pick this up in a real patient is a different question...