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Difficulty: EasyGeneral Internal Medicine

A 68-year-old man presents to the emergency department with progressively worsening shortness of breath over the past 3 days. He has a history of ischemic cardiomyopathy with a reduced ejection fraction and severe chronic obstructive pulmonary disease. The patient reports waking up in the middle of the night gasping for air and has required three pillows to sleep comfortably. His temperature is 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), blood pressure is 155/90155/90 mm Hg, pulse is 110110/min, and respirations are 2424/min. Oxygen saturation is 91%91\% on room air. Physical examination reveals an elevated jugular venous pressure, an S3 gallop, and diffuse bilateral crackles at the lung bases. There is 3+ bilateral pitting edema up to the mid-calves. Laboratory testing demonstrates a brain natriuretic peptide (BNP) level of 950950 pg/mL (normal: <100<100 pg/mL). Which of the following is the most appropriate next step in management?

  1. Intravenous furosemideAnswer
  2. B
    Intravenous methylprednisolone
  3. C
    Oral azithromycin
  4. D
    Inhaled ipratropium
  5. E
    Oral amoxicillin-clavulanate

Answer

Intravenous furosemide
The correct answer is intravenous furosemide. This patient's presentation of progressive dyspnea, orthopnea, elevated jugular venous pressure, an S3 gallop, bibasilar crackles, and severe pitting edema is the classic clinical picture of acute decompensated heart failure (ADHF). The markedly elevated brain natriuretic peptide (BNP) level further confirms this diagnosis over a primary pulmonary issue. The cornerstone of initial therapy for ADHF is the administration of intravenous loop diuretics, such as furosemide. These agents effectively reduce volume overload and alleviate pulmonary congestion by decreasing cardiac preload.

Step-by-Step Solution

1
Synthesize the patient's symptoms, physical examination, and laboratory findings to establish a diagnosis.
The patient has orthopnea, an S3 gallop, elevated jugular venous pressure, bibasilar crackles, pitting edema, and an elevated BNP level, which collectively diagnose acute decompensated heart failure.
Although the patient has a history of COPD, distinguishing between a COPD exacerbation and heart failure requires identifying signs of fluid overload, which are prominent here.
2
Determine the most appropriate initial management for the confirmed diagnosis.
Intravenous furosemide is selected as the next best step.
Intravenous loop diuretics rapidly induce diuresis and venodilation, decreasing cardiac preload and resolving pulmonary congestion in acute decompensated heart failure.

Key Concept

Acute decompensated heart failure is characterized by signs of volume overload (elevated jugular venous pressure, S3 gallop, peripheral edema) and is primarily managed with intravenous loop diuretics to rapidly reduce preload.
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Topics

General Internal Medicine

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