A 72-year-old man is brought to the emergency department from an extended care facility du… — USMLE Step 2 CK

A 72-year-old man is brought to the emergency department from an extended care facility due to progressively worsening shortness of breath, generalized weakness, and a nonproductive cough over the past $48$ hours. He tells the physician, "I just feel so tired and low lately, I can barely get out of bed." His medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$ , severe chronic obstructive pulmonary disease (COPD), bipolar disorder, and hypothyroidism. Three days ago, he underwent an uncomplicated open right inguinal hernia repair. His current medications include lisinopril, metoprolol succinate, tiotropium, and lithium.

Vital signs are temperature $37.7^\circ\text{C}$ ( $99.9^\circ\text{F}$ ), pulse $118$ /min and irregularly irregular, blood pressure $160/92$ mmHg, respiratory rate $26$ /min, and oxygen saturation $89\%$ on room air.

Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is elevated to $11$ cm $\text{H}_2\text{O}$ . Lung auscultation reveals bilateral basilar crackles and diffuse end-expiratory wheezing. Cardiac auscultation demonstrates an irregularly irregular rhythm without significant murmurs. The abdominal surgical incision is clean, dry, and intact with no surrounding erythema.

Laboratory results:
Brain natriuretic peptide (BNP): $950$ pg/mL
Thyroid-stimulating hormone (TSH): $0.2$ $\mu$ U/mL (normal: $0.5-5.0$ )
Free thyroxine (T4): $0.7$ ng/dL (normal: $0.9-1.7$ )

An electrocardiogram shows atrial fibrillation with a rapid ventricular response and no acute ST-segment changes. Which of the following is the most appropriate next step in management?

Intravenous furosemideAnswer
B
Systemic corticosteroids and nebulized ipratropium
C
Abdominal computed tomography scan
D
Intravenous levothyroxine
E
Initiation of sertraline therapy

Answer

The most appropriate next step in management is the administration of intravenous furosemide.

The correct intervention is the administration of intravenous furosemide. This patient presents with classic signs of acute decompensated heart failure (ADHF), including progressive dyspnea, hypoxia, elevated jugular venous pressure, basilar crackles, and an elevated brain natriuretic peptide (BNP) level. His presentation was likely precipitated by new-onset or poorly controlled atrial fibrillation with a rapid ventricular response, common in patients with ischemic cardiomyopathy. Intravenous loop diuretics are the cornerstone of initial management for ADHF, as they quickly induce diuresis and venodilation, directly reducing pulmonary capillary wedge pressure and relieving pulmonary edema.

Step-by-Step Solution

Evaluate the patient's acute respiratory distress and clinical presentation.

The patient presents with hypoxia, elevated jugular venous pressure, bilateral crackles, diffuse wheezing, and a significantly elevated BNP (

950

pg/mL) in the setting of rapid atrial fibrillation.

Identifying the primary cause of acute clinical deterioration is essential for prioritizing life-saving interventions.

Differentiate between cardiogenic and pulmonary etiologies of dyspnea.

The clinical picture strongly indicates acute decompensated heart failure (ADHF) with cardiac asthma, rather than a primary COPD exacerbation.

While wheezing can occur in COPD, the simultaneous presence of volume overload signs (elevated JVP, basilar crackles, high BNP) confirms cardiogenic pulmonary edema as the primary driver.

Determine the most appropriate initial pharmacological intervention.

Intravenous furosemide is the treatment of choice.

Loop diuretics rapidly reduce intravascular volume and venous return, decreasing pulmonary congestion and alleviating the life-threatening symptoms of ADHF.

Key Concept

Patients with acute decompensated heart failure can present with wheezing (cardiac asthma) that must be clinically distinguished from COPD exacerbations to ensure the prompt administration of intravenous loop diuretics.

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