During a routine follow-up appointment, a 65-year-old female patient complains of increasi… — USMLE Step 2 CK

During a routine follow-up appointment, a $65$ -year-old female patient complains of increasing difficulty breathing over the last $5$ days. She notes that she can no longer sleep in her bed and has spent the last two nights in a reclining chair. Her medical history includes long-standing hypertension, stable angina, and type 2 diabetes mellitus. She denies any fever, productive sputum, or recent sick contacts. Vital signs reveal a blood pressure of $162/88\text{ mm Hg}$ , a heart rate of $95\text{/min}$ , and a respiratory rate of $22\text{/min}$ . Oxygen saturation is $93\%$ on ambient air. Cardiovascular examination demonstrates elevated jugular venous pressure and an audible S3 gallop. Pulmonary auscultation reveals crackles at the bases of both lungs. Examination of the lower extremities shows significant $2+$ bilateral pitting edema. Laboratory testing is notable for a B-type natriuretic peptide (BNP) level of $920\text{ pg/mL}$ , a normal leukocyte count, and normal thyroid-stimulating hormone (TSH) and free T4 levels. An arterial blood gas shows a pH of $7.43$ , $\text{pCO}_2$ of $34\text{ mm Hg}$ , and $\text{pO}_2$ of $72\text{ mm Hg}$ . Which of the following is the most appropriate next step in the pharmacologic management of this patient?

Intravenous furosemideAnswer
B
Inhaled albuterol and ipratropium
C
Oral azithromycin
D
Intravenous sodium bicarbonate
E
Oral levothyroxine

Answer

Intravenous furosemide

The patient's clinical presentation of orthopnea (sleeping in a reclining chair), elevated jugular venous pressure, an S3 gallop, bibasilar lung crackles, and peripheral edema, combined with a significantly elevated B-type natriuretic peptide (BNP) level, confirms a clear diagnosis of acute decompensated heart failure (ADHF) with substantial volume overload. The most appropriate initial pharmacological treatment for ADHF is the administration of an intravenous loop diuretic, such as furosemide. Loop diuretics effectively promote robust diuresis and venodilation, which rapidly decreases cardiac preload and improves pulmonary congestion and symptoms of dyspnea.

Step-by-Step Solution

Analyze the patient's clinical presentation and physical examination findings.

The patient presents with orthopnea, elevated jugular venous pressure, an S3 gallop, bibasilar lung crackles, and bilateral pitting edema.

To identify the classic signs of volume overload and determine the primary pathophysiological process.

Evaluate the supporting laboratory and diagnostic results.

The highly elevated BNP level (

920\text{ pg/mL}

) strongly supports a cardiac etiology, while the normal leukocyte count and thyroid tests rule out infection and hypothyroidism.

To confirm the diagnosis of acute decompensated heart failure (ADHF) and exclude important differential diagnoses.

Determine the most appropriate initial pharmacological intervention for the confirmed diagnosis.

Intravenous furosemide is selected as the initial management.

Intravenous loop diuretics are the first-line treatment to rapidly induce diuresis, reduce preload, and relieve pulmonary congestion in ADHF.

Key Concept

Recognition and initial pharmacological management of volume overload in acute decompensated heart failure.

Estimated Time:45s

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