A 55-year-old male presents to the triage desk of the local hospital reporting progressive… — USMLE Step 2 CK

A 55-year-old male presents to the triage desk of the local hospital reporting progressive difficulty breathing that began two days ago. He states that he has been unable to sleep in his bed due to a feeling of suffocation and has been resting in a recliner chair. He also notes a new cough that occasionally produces pink, frothy sputum. Medical history is significant for essential hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Current medications include lisinopril, amlodipine, and metformin. Vital signs demonstrate a temperature of $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure of $178/102$ mmHg, pulse of 112/min, and respiratory rate of 26/min. Pulse oximetry reveals an oxygen saturation of 89% on room air. On physical examination, the patient appears distressed and is using accessory muscles to breathe. Evaluation of the neck shows jugular venous distention up to the angle of the mandible while seated upright. Cardiac auscultation is notable for a regular, rapid rhythm and a low-frequency diastolic sound heard best at the cardiac apex. Lung auscultation reveals bilateral expiratory wheezes and fine crackles extending from the bases to the mid-lung zones. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

Intravenous furosemideAnswer
B
Nebulized albuterol
C
Intravenous methylprednisolone
D
Intravenous ceftriaxone and azithromycin
E
Intravenous magnesium sulfate

Answer

Intravenous furosemide

The correct answer is intravenous furosemide. This patient is presenting with classic signs of acute decompensated heart failure (ADHF) leading to pulmonary edema. Key diagnostic clues include orthopnea (sleeping in a recliner), pink frothy sputum, marked hypertension, elevated jugular venous pressure, an S3 gallop, and bilateral crackles. The diffuse wheezing is a manifestation of peribronchial airway edema secondary to fluid overload, a phenomenon often termed 'cardiac asthma.' The immediate priority in managing ADHF with volume overload is preload reduction, which is rapidly achieved with intravenous loop diuretics like furosemide.

Step-by-Step Solution

Identify the primary clinical syndrome based on presenting symptoms and vital signs.

The patient presents with severe dyspnea, orthopnea, hypoxemia, and severe hypertension, indicating acute respiratory distress of a cardiopulmonary origin.

Initial stabilization requires determining whether the primary etiology is pulmonary (e.g., COPD, pneumonia) or cardiac (e.g., heart failure).

Analyze the physical examination findings to differentiate between heart failure and primary pulmonary disease.

Findings of jugular venous distention, an S3 gallop (low-frequency diastolic sound), pink frothy sputum, and bilateral crackles strongly indicate left ventricular volume overload and elevated filling pressures.

While the patient has a smoking history and wheezing, these specific volume-overload signs point to acute decompensated heart failure (ADHF) causing 'cardiac asthma' rather than a COPD exacerbation.

Select the most appropriate initial pharmacotherapy for the identified condition.

Intravenous loop diuretics (e.g., furosemide) are indicated to rapidly reduce preload and relieve pulmonary edema.

Immediate diuresis is the cornerstone of ADHF management to improve oxygenation and reduce symptoms.

Key Concept

Diagnosis and acute management of acute decompensated heart failure presenting with cardiac asthma.

Estimated Time:1m 30s

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