Examkin

Question

Difficulty: MediumPreoperative and Postoperative Care

A physician assesses a 77-year-old female patient on the third day following surgical repair of a right femoral neck fracture. The patient reports a sudden onset of severe difficulty breathing and the inability to lie flat in bed, which began approximately one hour ago. Her past medical history includes essential hypertension, diet-controlled type 2 diabetes, and severe tobacco use disorder with associated chronic obstructive pulmonary disease. Since her operation, she has received continuous isotonic saline infusions due to transient intraoperative hypotension. Current vital signs demonstrate a temperature of 38.1°C (100.6°F), blood pressure of 168/92 mmHg, pulse of 115/min, and respirations of 28/min. Pulse oximetry shows an oxygen saturation of 86% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates bilateral dependent fine inspiratory crackles without any expiratory wheezing. Cardiac evaluation reveals a regular tachycardia with a distinct early diastolic extra heart sound. The surgical incision is clean, dry, and intact. Which of the following is the most appropriate initial medical intervention for this patient?

  1. Intravenous loop diuretic administrationAnswer
  2. B
    Administration of inhaled short-acting bronchodilators
  3. C
    Administration of intravenous broad-spectrum antimicrobials
  4. D
    Immediate wound exploration and bedside debridement
  5. E
    Therapeutic systemic anticoagulation

Answer

Intravenous loop diuretic administration
This patient presents with acute decompensated heart failure (ADHF) likely triggered by aggressive postoperative intravenous fluid resuscitation. The diagnosis is strongly supported by the clinical triad of acute respiratory distress with orthopnea, signs of right-sided fluid overload (prominent jugular venous distention), and signs of left-sided fluid overload (bilateral fine inspiratory crackles, hypoxemia, and an S3 gallop). The S3 gallop is highly specific for elevated left ventricular end-diastolic filling pressures. The most appropriate initial intervention is the administration of an intravenous loop diuretic (e.g., furosemide) to rapidly reduce intravascular volume, decrease ventricular preload, and alleviate pulmonary edema.

Step-by-Step Solution

1
Identify the patient's acute respiratory distress, orthopnea, hypoxemia, JVD, crackles, and S3 gallop.
These are classic signs of acute decompensated heart failure (ADHF) with cardiogenic pulmonary edema.
Accurate interpretation of physical exam findings is necessary to differentiate the etiology of postoperative dyspnea.
2
Recognize the iatrogenic trigger in the clinical history.
The patient received continuous postoperative isotonic fluid resuscitation, which precipitated volume overload in an elderly patient with underlying cardiovascular risk factors.
Understanding the precipitating factor confirms the diagnosis of iatrogenic hypervolemia.
3
Determine the most appropriate immediate medical intervention.
Select an intravenous loop diuretic to rapidly reduce intravascular volume and preload.
Loop diuretics provide immediate symptomatic relief in ADHF by decreasing pulmonary capillary wedge pressure.

Key Concept

Differentiating acute decompensated heart failure from COPD exacerbations in the postoperative period to guide appropriate initial diuresis.
Rate this question

Topics

Preoperative and Postoperative Care

More questions from this topic