Examkin

Question

Difficulty: MediumPulmonary and Critical Care

A 74-year-old woman is brought to the emergency department due to a 2-day history of progressively worsening shortness of breath and a persistent cough. Her medical history is significant for hypertension, type 2 diabetes mellitus, and a 45-pack-year smoking history. She currently smokes half a pack of cigarettes daily. The patient reports that her dyspnea worsens significantly when she lies flat in bed. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 172/96 mm Hg, pulse of 114/min, and respiratory rate of 28/min. Pulse oximetry shows an oxygen saturation of 88% on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates diffuse bilateral wheezing with crackles at the lung bases. Cardiac examination reveals a regular tachycardia with a prominent S3 gallop. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

  1. Intravenous furosemideAnswer
  2. B
    Intravenous methylprednisolone
  3. C
    Inhaled albuterol and ipratropium
  4. D
    Oral azithromycin
  5. E
    Intravenous piperacillin-tazobactam

Answer

Intravenous furosemide
The correct answer is intravenous furosemide because this patient is presenting with acute decompensated heart failure (ADHF). Although her heavy smoking history and wheezing might initially suggest a COPD exacerbation, the classic signs of volume overload and left ventricular failure—including orthopnea, elevated jugular venous pressure, bibasilar crackles, and an S3 gallop—confirm cardiogenic pulmonary edema. The wheezing she is experiencing is known as 'cardiac asthma' and is caused by peribronchial edema secondary to the heart failure. Intravenous loop diuretics like furosemide are the first-line pharmacologic therapy for ADHF to rapidly reduce volume overload, decrease preload, and alleviate respiratory symptoms.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and physical exam findings.
The patient has acute dyspnea, orthopnea, hypoxia, elevated jugular venous pressure, bibasilar crackles, wheezing, and an S3 gallop.
Identifying the constellation of findings is necessary to determine the primary underlying pathology.
2
Differentiate between a chronic obstructive pulmonary disease (COPD) exacerbation and acute decompensated heart failure (ADHF).
Despite the significant smoking history and the presence of wheezing, findings such as elevated jugular venous pressure, orthopnea, and particularly an S3 gallop strongly confirm a cardiogenic etiology (ADHF) rather than a primary pulmonary exacerbation.
Wheezing can occur in heart failure ('cardiac asthma') due to peribronchial edema, making clinical differentiation critical to avoid incorrect management.
3
Select the appropriate initial pharmacologic therapy based on the established diagnosis of ADHF.
Intravenous furosemide (a loop diuretic) is selected.
Loop diuretics rapidly reduce volume overload and preload, relieving pulmonary congestion and improving respiratory symptoms in ADHF.

Key Concept

Differentiation and management of acute decompensated heart failure versus COPD exacerbation.
Rate this question

Topics

Pulmonary and Critical Care

More questions from this topic