An 81-year-old woman arrives at the emergency room accompanied by her son due to worsening… — USMLE Step 2 CK

An $81$ -year-old woman arrives at the emergency room accompanied by her son due to worsening difficulty breathing and a persistent cough over the past $5$ days. She tells the physician that she needs to prop herself up on three pillows to sleep comfortably at night. Her medical history is significant for hypertension, coronary artery disease, and a $45$ -pack-year history of smoking. Her vital signs include a temperature of $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), blood pressure of $160/92 \text{ mm Hg}$ , pulse of $102/\text{min}$ , and a respiratory rate of $24/\text{min}$ . Oxygen saturation is $90\%$ on ambient air. Physical examination shows engorged neck veins when she is sitting at a $45$ -degree angle. Auscultation of the lungs reveals bilateral crackles at the bases and scattered high-pitched expiratory wheezes. Cardiac auscultation reveals an extra diastolic heart sound heard shortly after S $2$ . Examination of the legs shows bilateral pitting edema up to the mid-calves. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

A
Administration of inhaled albuterol and oral prednisone
B
Administration of inhaled tiotropium
Administration of intravenous furosemideAnswer
D
Measurement of arterial blood gas to calculate expected metabolic compensation
E
Administration of intravenous piperacillin-tazobactam

Answer

Administration of intravenous furosemide

This patient is presenting with acute decompensated heart failure (ADHF). Key identifying features include orthopnea (needing pillows to sleep), elevated jugular venous pressure, bilateral basilar crackles, a prominent S3 gallop (the extra diastolic heart sound), and peripheral pitting edema. The expiratory wheezing observed in this patient is often referred to as 'cardiac asthma,' which occurs because peribronchial edema causes physical compression and narrowing of the small airways. The most appropriate initial management for a patient in respiratory distress due to volume overload from ADHF is the administration of an intravenous loop diuretic, such as furosemide. This intervention rapidly decreases cardiac preload, reduces pulmonary congestion, and provides symptomatic relief.

Step-by-Step Solution

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

The patient exhibits orthopnea, jugular venous distention, basilar crackles, an S3 gallop (extra diastolic sound after S2), and lower extremity edema.

These findings are the classic textbook signs of volume overload and elevated left ventricular filling pressures.

Determine the etiology of the expiratory wheezes in this specific context.

Although the patient has a heavy smoking history, the predominant signs indicate acute decompensated heart failure. The wheezing represents 'cardiac asthma' resulting from peribronchial airway edema.

Accurately diagnosing the root cause prevents the administration of therapies (like bronchodilators or steroids) that do not address the underlying fluid overload.

Select the most appropriate initial pharmacological intervention for the identified syndrome.

An intravenous loop diuretic, such as furosemide, is indicated.

Loop diuretics rapidly reduce cardiac preload and promote diuresis, directly mitigating the pulmonary congestion and relieving the patient's respiratory distress.

Key Concept

The clinical differentiation of acute decompensated heart failure from a COPD exacerbation relies on identifying distinct signs of volume overload (such as an S3 gallop, jugular venous distention, basilar crackles, and peripheral edema), which dictates immediate treatment with intravenous loop diuretics.

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