An emergency medical services team brings a 76-year-old female resident of a skilled nursi… — USMLE Step 2 CK

An emergency medical services team brings a $76$ -year-old female resident of a skilled nursing facility to the hospital because of severe respiratory distress that awakened her from sleep. The patient is unable to speak in full sentences and is actively coughing up pink, frothy sputum. Her past medical history is notable for systemic hypertension, osteoarthritis, and a $30$ -pack-year history of smoking (quit $15$ years ago). Two weeks ago, she was prescribed daily naproxen for worsening knee pain.

Upon arrival, her temperature is $36.9^\circ\text{C}$ ( $98.4^\circ\text{F}$ ), blood pressure is $192/108\text{ mmHg}$ , heart rate is $118/\text{min}$ , and respiratory rate is $30/\text{min}$ . Oxygen saturation is $84\%$ on room air.

Physical examination displays prominent use of accessory respiratory muscles. The internal jugular vein is visibly distended while the patient is sitting upright. Chest auscultation reveals diffuse expiratory wheezes and coarse crackles extending halfway up both lung fields. Cardiac examination is significant for a rapid, regular rhythm with a distinct low-frequency sound heard just after $S_2$ .

An electrocardiogram shows sinus tachycardia with left ventricular hypertrophy but no acute ischemic changes.

Which of the following is the most appropriate initial pharmacological therapy for this patient?

Intravenous furosemideAnswer
B
Nebulized albuterol and intravenous methylprednisolone
C
Intravenous piperacillin-tazobactam
D
Intravenous metoprolol
E
Intravenous sodium bicarbonate

Answer

Intravenous furosemide

Intravenous furosemide is the correct choice because the patient is presenting with acute decompensated heart failure (ADHF). This is evidenced by severe dyspnea, an

S_3

gallop (the low-frequency sound after

S_2

), jugular venous distension, and pink frothy sputum. The recent initiation of an NSAID (naproxen) likely caused sodium and water retention, exacerbating her hypertension and precipitating the heart failure episode. Intravenous loop diuretics like furosemide rapidly decrease preload through direct venodilation and subsequent brisk diuresis, effectively relieving the acute pulmonary edema.

Step-by-Step Solution

Analyze the patient's symptoms, vital signs, and recent history.

The patient has acute respiratory distress, severe hypertension, hypoxia, and recently started an NSAID (naproxen).

To establish the acuity of the presentation and identify potential triggers for the decompensation.

Interpret the physical examination findings.

The presence of an

S_3

gallop, jugular venous distension (JVD), bibasilar crackles, and pink, frothy sputum strongly indicates volume overload and elevated left ventricular end-diastolic pressure.

To differentiate between pulmonary (e.g., COPD, pneumonia) and cardiac causes of severe dyspnea.

Synthesize the findings to establish a diagnosis.

The diagnosis is acute decompensated heart failure (ADHF) causing acute pulmonary edema, likely precipitated by NSAID-induced fluid retention and exacerbation of hypertension.

NSAids inhibit prostaglandins, reducing renal blood flow and causing sodium and water retention.

Select the most appropriate initial pharmacological therapy.

Administer an intravenous loop diuretic (such as furosemide).

Loop diuretics rapidly reduce central venous pressure and pulmonary capillary wedge pressure through immediate venodilation and subsequent diuresis, relieving the pulmonary edema.

Key Concept

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

Alternative Method

In patients with acute decompensated heart failure and severe hypertension, intravenous vasodilators (such as nitroglycerin) are often used as an adjunct alongside loop diuretics to rapidly reduce both preload and afterload. Non-invasive positive pressure ventilation (NIPPV) is also a critical non-pharmacological adjunct to decrease work of breathing and reduce preload.

Estimated Time:1m 30s

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