A 74-year-old woman presents to the acute care clinic with a 2-day history of progressivel… — USMLE Step 2 CK

A $74$ -year-old woman presents to the acute care clinic with a $2$ -day history of progressively worsening shortness of breath. She has a medical history significant for coronary artery disease, for which she underwent percutaneous coronary intervention $5$ years ago, and chronic obstructive pulmonary disease due to a $45$ -pack-year smoking history. Over the past two nights, she has been unable to sleep flat in her bed, requiring multiple pillows to breathe comfortably. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $162/90\text{ mmHg}$ , pulse is $115/\text{min}$ , and respiratory rate is $28/\text{min}$ . Pulse oximetry shows $88\%$ on room air. Physical examination reveals distended jugular veins when the patient is seated upright. Pulmonary auscultation reveals bilateral expiratory wheezes and dullness to percussion at the bases. Cardiac auscultation demonstrates a regular tachycardia and an early diastolic, low-frequency sound. Which of the following is the most appropriate initial therapy for this patient?

A
Nebulized albuterol and ipratropium
B
Intravenous methylprednisolone
C
Oral azithromycin
Intravenous bumetanideAnswer
E
Inhaled tiotropium

Answer

The correct answer is the intravenous administration of a loop diuretic, such as bumetanide.

The correct answer is the administration of an intravenous loop diuretic, such as bumetanide. This patient's presentation of worsening dyspnea, orthopnea, elevated jugular venous pressure, bibasilar dullness (suggestive of pleural effusions), and an S3 gallop (an early diastolic, low-frequency sound) is highly characteristic of acute decompensated heart failure (ADHF) with volume overload. Wheezing can frequently occur in ADHF (often termed 'cardiac asthma') due to peribronchial edema, which can be mistakenly attributed to a COPD exacerbation, especially in patients with a significant smoking history. Intravenous loop diuretics are the first-line therapy for patients with ADHF and evidence of volume overload. They act on the thick ascending limb of the loop of Henle to promote potent diuresis, thereby reducing intravascular volume, lowering central venous pressure, and relieving pulmonary congestion.

Step-by-Step Solution

Identify the primary clinical syndrome based on the patient's history and physical exam findings.

The patient presents with severe dyspnea, orthopnea, jugular venous distention, bibasilar dullness, and an S3 gallop (early diastolic sound), which strongly indicate acute decompensated heart failure (ADHF).

Although the patient has a history of COPD and presents with wheezing (cardiac asthma), the presence of clear fluid overload signs (JVD, S3 gallop) points to a cardiac rather than pulmonary etiology for her acute deterioration.

Determine the most appropriate initial pharmacological management for acute decompensated heart failure.

Initial treatment involves reducing volume overload and improving oxygenation, primarily through the administration of intravenous loop diuretics (e.g., bumetanide, furosemide).

Loop diuretics rapidly reduce intravascular volume and venous return (preload), alleviating pulmonary congestion and improving respiratory symptoms.

Key Concept

Patients with acute decompensated heart failure can present with wheezing (cardiac asthma); however, the presence of orthopnea, jugular venous distention, and an S3 gallop helps differentiate it from a COPD exacerbation. Initial management centers on intravenous loop diuretics.

Estimated Time:1m 15s

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