Examkin

Question

Difficulty: MediumGeneral Internal Medicine

Progressive respiratory distress over the past 72 hours brings a retired teacher to the emergency department. The 72-year-old man reports that he cannot sleep flat in bed due to a suffocating sensation, which is accompanied by a cough producing frothy sputum. He has a 45-pack-year history of smoking, hypertension, and type 2 diabetes mellitus. His daily medications are amlodipine and metformin. Vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 162/94 mm Hg, heart rate of 108/min, and respiratory rate of 26/min. Pulse oximetry on ambient air indicates an oxygen saturation of 88%. On physical examination, the jugular veins are distended to 10 cm H2O above the sternal angle. Auscultation of the lungs reveals widespread expiratory wheezes and fine crackles at both lung bases. Cardiac examination shows a regular, rapid rhythm with a distinct third heart sound (S3). Examination of the lower extremities shows bilateral 1+ pitting edema. Electrocardiography shows sinus tachycardia without ischemic changes. Chest radiography is pending. Which of the following is the most appropriate next step in management?

  1. A
    Nebulized albuterol and ipratropium
  2. B
    Oral prednisone
  3. Intravenous furosemideAnswer
  4. D
    Intravenous ceftriaxone and azithromycin
  5. E
    Measurement of serum brain natriuretic peptide

Answer

Intravenous furosemide
The correct answer is the administration of intravenous furosemide. The patient's clinical presentation—orthopnea, elevated jugular venous pressure, bibasilar crackles, an S3 gallop, and peripheral edema—is highly specific for acute decompensated heart failure (ADHF) leading to pulmonary edema. The presence of wheezing in this context is often referred to as 'cardiac asthma,' which occurs due to peribronchial edema causing airway narrowing. Patients with a significant smoking history are at high risk for COPD, which can make the differentiation challenging, but the clear signs of volume overload confirm ADHF. The initial management of ADHF focuses on preload reduction and symptom relief, which is primarily achieved with intravenous loop diuretics (e.g., furosemide) and supplemental oxygen. Waiting for further diagnostic testing is inappropriate when the clinical diagnosis is evident and the patient is in acute respiratory distress.

Step-by-Step Solution

1
Analyze the patient's symptoms and vital signs.
The patient has acute respiratory distress, hypoxemia, orthopnea, and a cough producing frothy sputum.
To determine the severity and nature of the respiratory compromise.
2
Evaluate the physical examination findings.
Findings include elevated jugular venous pressure, bilateral crackles, wheezing, an S3 gallop, and peripheral edema.
To differentiate between primary pulmonary and primary cardiac causes of dyspnea.
3
Synthesize the findings to establish a clinical diagnosis.
The combination of volume overload signs (JVP, S3, edema) and pulmonary edema confirms acute decompensated heart failure. The wheezing represents 'cardiac asthma' rather than a primary obstructive airway process.
Accurate diagnosis is required to select the appropriate targeted therapy and avoid harmful interventions.
4
Select the most appropriate initial pharmacological management.
Intravenous furosemide is chosen.
Loop diuretics provide rapid preload reduction and diuresis, which are urgently needed to relieve pulmonary congestion in acute decompensated heart failure.

Key Concept

Clinical differentiation and initial management of acute decompensated heart failure presenting with cardiac asthma.
Rate this question

Topics

General Internal Medicine

More questions from this topic