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Difficulty: MediumGeneral Internal Medicine

A 7272-year-old woman is brought to the emergency department by her daughter due to a 33-day history of progressively worsening shortness of breath. The patient reports that she has been unable to sleep in her bed for the past two nights, opting to sleep in a recliner chair instead. Her medical history is significant for hypertension, type 2 diabetes mellitus, and a 4545-pack-year smoking history. She was diagnosed with chronic obstructive pulmonary disease (COPD) five years ago. Current medications include amlodipine, metformin, and an albuterol inhaler as needed. Her temperature is 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), blood pressure is 168/94 mmHg168/94\text{ mmHg}, heart rate is 115/min115/\text{min}, respiratory rate is 26/min26/\text{min}, and oxygen saturation is 85%85\% on room air. She appears in respiratory distress and is using accessory muscles of respiration. Jugular venous pressure is estimated at 12 cm H2O12\text{ cm H}_2\text{O}. Lung auscultation reveals bilateral basilar dullness to percussion, diffuse fine crackles extending to the mid-lung fields, and scattered expiratory wheezes. Cardiac examination shows a regular rhythm, tachycardia, and a prominent S3S_3 gallop. There is 3+3+ pitting edema of the bilateral lower extremities extending to the mid-calves. Which of the following is the most appropriate next step in management for this patient?

  1. A
    Intravenous methylprednisolone
  2. B
    Oral azithromycin
  3. Intravenous furosemideAnswer
  4. D
    Inhaled albuterol and ipratropium
  5. E
    Intravenous metoprolol

Answer

Intravenous furosemide
This patient's presentation of acute dyspnea, orthopnea (necessitating sleeping in a chair), elevated jugular venous pressure, an S3S_3 gallop, pulmonary crackles, and peripheral edema is highly characteristic of acute decompensated heart failure (ADHF) with pulmonary edema. While she has a history of COPD and is actively wheezing, the wheezing is likely 'cardiac asthma' caused by peribronchial edema rather than primary bronchospasm. The presence of an S3S_3 gallop and profound volume overload points decisively to a cardiac etiology rather than a pure pulmonary one. The most appropriate initial step in management is the administration of an intravenous loop diuretic, such as furosemide, which rapidly decreases preload and improves pulmonary venous congestion.

Step-by-Step Solution

1
Analyze the patient's respiratory symptoms and physical examination findings.
The patient exhibits orthopnea, severe hypoxia, elevated jugular venous pressure, an S3S_3 gallop, bilateral crackles, and peripheral edema.
To differentiate between a respiratory etiology (COPD exacerbation) and a cardiac etiology (heart failure) for her acute dyspnea.
2
Interpret the significance of wheezing in this specific clinical context.
Despite her COPD history and the presence of wheezing, the prominent signs of fluid overload and an S3S_3 gallop indicate the wheezing is likely 'cardiac asthma' caused by peribronchial edema.
To avoid diagnostic momentum and misdiagnosing the primary event as a primary pulmonary exacerbation.
3
Determine the most appropriate initial pharmacological intervention based on the diagnosis.
Intravenous loop diuretics (e.g., furosemide) are indicated to quickly reduce preload and alleviate pulmonary edema.
Acute decompensated heart failure requires rapid volume reduction to improve oxygenation and mechanics.

Key Concept

Patients with acute decompensated heart failure can present with wheezing known as 'cardiac asthma'. Identifying fluid overload signs (elevated JVP, peripheral edema, S3S_3 gallop) is critical to differentiating this from a COPD exacerbation, as the primary treatment involves intravenous loop diuretics.
Estimated Time:1m 30s
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Topics

General Internal Medicine

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