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|SubCategory=Renal
|SubCategory=Renal
|Prompt=A 68 year old Caucasian male patient with a significant history of alcoholism presented to the emergency department for altered mental status.  He was unable to provide further history.  Physical examination revealed fetor hepaticus, spider nevi, and gynecomastia.  The patient’s abdomen was severely distended with shifting dullness. Following appropriate work-up, the diagnosis of hepatic cirrhosis was made.  Patient was closely followed for further treatment of his condition during hospital admission.  Upon discharge, the patient was prescribed spironolactone for moderate ascites.  The patient should be monitored for which of the following electrocardiogram (ECG) finding after initiation of spironolactone?
|Prompt=A 68 year old Caucasian male patient with a significant history of alcoholism presented to the emergency department for altered mental status.  He was unable to provide further history.  Physical examination revealed fetor hepaticus, spider nevi, and gynecomastia.  The patient’s abdomen was severely distended with shifting dullness. Following appropriate work-up, the diagnosis of hepatic cirrhosis was made.  Patient was closely followed for further treatment of his condition during hospital admission.  Upon discharge, the patient was prescribed spironolactone for moderate ascites.  The patient should be monitored for which of the following electrocardiogram (ECG) finding after initiation of spironolactone?
|Explanation=Spironolactone, a competitive aldosterone receptor antagonist, is an effective treatment for patients with severe heart failure and ascites due to hepatic failure.  Randomized Aldactone Evaluation Study (RALES) trial established spironolactone’s clinical benefit on survival in patients with severe heart failure.
|Explanation=Spironolactone, a competitive aldosterone receptor antagonist, is an effective treatment for patients with severe heart failure and ascites due to hepatic failure.  Randomized Aldactone Evaluation Study (RALES) trial established spironolactone’s clinical benefit on survival in patients with severe heart failure. Following initiation of spironolactone therapy, serum potassium concentrations should be periodically measured to monitor for hyperkalemia, a common adverse event.  Hyperkalemia is a potential side effect of spironolactone therapy due to inhibition of aldosterone’s physiologic activity in excreting potassium. Hence, spironolactone is described as a “potassium-sparing” diuretic.  A classical ECG finding of hyperkalemia is peaked T waves.
  Following initiation of spironolactone therapy, serum potassium concentrations should be periodically measured to monitor for hyperkalemia, a common adverse event.  Hyperkalemia is a potential side effect of spironolactone therapy due to inhibition of aldosterone’s physiologic activity in excreting potassium. Hence, spironolactone is described as a “potassium-sparing” diuretic.  A classical ECG finding of hyperkalemia is peaked T waves.


Educational Objective:
Educational Objective:
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Biecker E.  Diagnosis and therapy of ascites in liver cirrhosis.  World J Gastroenterol.  2011;17(10):1237-1248.
Biecker E.  Diagnosis and therapy of ascites in liver cirrhosis.  World J Gastroenterol.  2011;17(10):1237-1248.
|AnswerA=Two independent rhythms of P and QRS complexes
|AnswerA=Two independent rhythms of P and QRS complexes
|AnswerAExp=Third degree AV block is not commonly associated with spironolactone therapy.  AV blockade is commonly seen in patients receiving beta blockers and calcium channel blockers.  
|AnswerAExp=Third degree AV block is not commonly associated with spironolactone therapy.  AV blockade is commonly seen in patients receiving beta blockers and calcium channel blockers.
|AnswerB=“Saw tooth” appearance
|AnswerB=“Saw tooth” appearance
|AnswerBExp=“Saw tooth” appearance is the characteristic description of atrial flutter.  Spironolactone is not commonly associated with atrial flutter.  
|AnswerBExp=“Saw tooth” appearance is the characteristic description of atrial flutter.  Spironolactone is not commonly associated with atrial flutter.
|AnswerC=Peaked T waves
|AnswerC=Peaked T waves
|AnswerCExp=Peaked T waves on ECG is characteristic of hyperkalemia, a common side effect of spironolactone therapy.
|AnswerCExp=Peaked T waves on ECG is characteristic of hyperkalemia, a common side effect of spironolactone therapy.
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|AnswerE=Prolonged PR interval
|AnswerE=Prolonged PR interval
|AnswerEExp=Prolonged PR interval is characteristic of first degree AV block.  Spironolactone does not commonly cause first degree AV blockade.
|AnswerEExp=Prolonged PR interval is characteristic of first degree AV block.  Spironolactone does not commonly cause first degree AV blockade.
|RightAnswer=C
|Approved=No
|Approved=No
}}
}}

Revision as of 02:09, 10 September 2013
Author [[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type ExamType::USMLE Step 1
Main Category MainCategory::Pathology
Sub Category SubCategory::Renal
Prompt [[Prompt::A 68 year old Caucasian male patient with a significant history of alcoholism presented to the emergency department for altered mental status. He was unable to provide further history. Physical examination revealed fetor hepaticus, spider nevi, and gynecomastia. The patient’s abdomen was severely distended with shifting dullness. Following appropriate work-up, the diagnosis of hepatic cirrhosis was made. Patient was closely followed for further treatment of his condition during hospital admission. Upon discharge, the patient was prescribed spironolactone for moderate ascites. The patient should be monitored for which of the following electrocardiogram (ECG) finding after initiation of spironolactone?]]
Answer A AnswerA::Two independent rhythms of P and QRS complexes
Answer A Explanation AnswerAExp::Third degree AV block is not commonly associated with spironolactone therapy. AV blockade is commonly seen in patients receiving beta blockers and calcium channel blockers.
Answer B AnswerB::“Saw tooth” appearance
Answer B Explanation AnswerBExp::“Saw tooth” appearance is the characteristic description of atrial flutter. Spironolactone is not commonly associated with atrial flutter.
Answer C AnswerC::Peaked T waves
Answer C Explanation AnswerCExp::Peaked T waves on ECG is characteristic of hyperkalemia, a common side effect of spironolactone therapy.
Answer D AnswerD::ST-segment elevation in leads I and aVL
Answer D Explanation AnswerDExp::ST-segment elevation is seen in myocardial infarction
Answer E AnswerE::Prolonged PR interval
Answer E Explanation AnswerEExp::Prolonged PR interval is characteristic of first degree AV block. Spironolactone does not commonly cause first degree AV blockade.
Right Answer RightAnswer::C
Explanation [[Explanation::Spironolactone, a competitive aldosterone receptor antagonist, is an effective treatment for patients with severe heart failure and ascites due to hepatic failure. Randomized Aldactone Evaluation Study (RALES) trial established spironolactone’s clinical benefit on survival in patients with severe heart failure. Following initiation of spironolactone therapy, serum potassium concentrations should be periodically measured to monitor for hyperkalemia, a common adverse event. Hyperkalemia is a potential side effect of spironolactone therapy due to inhibition of aldosterone’s physiologic activity in excreting potassium. Hence, spironolactone is described as a “potassium-sparing” diuretic. A classical ECG finding of hyperkalemia is peaked T waves.

Educational Objective: Spironolactone, a competitive aldosterone receptor antagonist, is an effective treatment for patients with hepatic failure and ascites. Hyperkalemia is a common side effect of spironolactone therapy that manifests as peaked T waves on ECG.

References: Nappi JM, Sieg A. Aldosterone and aldosterone receptor antagonists in patients with chronic heart failure. Vasc Health Risk Manag. 2011;7:353-363.

Biecker E. Diagnosis and therapy of ascites in liver cirrhosis. World J Gastroenterol. 2011;17(10):1237-1248.
Educational Objective:
References: ]]

Approved Approved::No
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