Mitral stenosis Quiz: Ace Your Exams
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A 72-year-old woman presents to the emergency department with severe shortness of breath and worsening lower extremity edema. She has a 3-year history of severe mitral stenosis. A transthoracic echocardiogram two months ago showed worsening mitral stenosis, as well as reduced left ventricular ejection fraction (LVEF) and right ventricular hypertrophy (RVH). Three weeks ago, she suffered a traumatic subarachnoid hemorrhage after a fall. She also has a past medical history of hypertension and paroxysmal atrial fibrillation. Her current medications include amlodipine, furosemide, and metoprolol. The patient is admitted to the hospital and started on intravenous bumetanide and oral metoprolol. Temperature is 37.2ºC (99.0ºF), pulse is 54/min, respiratory rate is 16/min, blood pressure is 98/66 mmHg, and SpO2 is 95% on 2 liters nasal cannula oxygen. Cardiac exam reveals a diastolic rumble, loud S1, and opening snap. Pulmonary exam reveals rales at the bases bilaterally. There is 2+ pitting edema to below the knees bilaterally. Intake and output reports show she is 1.3 liters net negative over the past 24 hours. Which of the following is the best next step in management?
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