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Difficulty: EasyGeneral Internal Medicine

A 68-year-old man presents to the clinic with progressive dyspnea and a nonproductive cough over the past week. He reports waking up several times at night feeling starved for air and has recently started using three pillows to sleep comfortably. His medical history includes hypertension, hyperlipidemia, and a 30-pack-year smoking history, though he quit 10 years ago. Current medications include amlodipine and atorvastatin. Blood pressure is 155/92 mm Hg, pulse is 96/min, and respirations are 22/min. Oxygen saturation is 92% on room air. Physical examination shows elevated jugular venous pressure. Lung auscultation reveals bibasilar crackles and mild expiratory wheezing. There is 2+ pitting edema in the bilateral lower extremities. Which of the following is the most appropriate next step in pharmacological management?

  1. Intravenous furosemideAnswer
  2. B
    Oral prednisone
  3. C
    Inhaled albuterol and ipratropium
  4. D
    Oral azithromycin
  5. E
    Intravenous piperacillin-tazobactam

Answer

Intravenous furosemide
The correct answer is intravenous furosemide. This patient's presentation of orthopnea (using multiple pillows), paroxysmal nocturnal dyspnea, elevated jugular venous pressure, bibasilar crackles, and bilateral lower extremity edema is classic for acute decompensated heart failure (ADHF). The presence of mild wheezing is also common in ADHF due to peribronchial edema, a phenomenon often referred to as 'cardiac asthma.' The mainstay of initial therapy for ADHF is reducing volume overload and cardiac preload with intravenous loop diuretics, such as furosemide.

Step-by-Step Solution

1
Analyze the patient's presentation and physical exam findings.
The patient exhibits orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, bibasilar crackles, and bilateral pitting edema.
These findings are the hallmark clinical signs of volume overload and acute decompensated heart failure (ADHF).
2
Determine the appropriate initial therapy for this diagnosis.
Loop diuretics, such as intravenous furosemide, should be administered.
Intravenous loop diuretics provide rapid symptom relief by increasing diuresis, reducing volume overload, and decreasing cardiac preload.

Key Concept

Diagnosis and initial management of acute decompensated heart failure, distinguishing it from a COPD exacerbation.
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Topics

General Internal Medicine

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