A 70-year-old woman presents to the emergency department with severe shortness of breath a… — USMLE Step 2 CK

A $70$ -year-old woman presents to the emergency department with severe shortness of breath and wheezing that began $2$ hours ago. She has a history of poorly controlled hypertension and a $30$ -pack-year smoking history. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $170/95\text{ mmHg}$ , pulse is $112/\text{min}$ , and oxygen saturation is $88\%$ on room air. Physical examination reveals distended jugular veins, a third heart sound (S3) on cardiac auscultation, and bilateral diffuse wheezing intermixed with bibasilar crackles. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

Intravenous furosemideCevap
B
Inhaled albuterol and ipratropium
C
Intravenous methylprednisolone
D
Oral metoprolol
E
Intravenous ceftriaxone and azithromycin

Cevap

Intravenous furosemide is the most appropriate initial therapy.

The correct option provides a loop diuretic, which is the cornerstone of initial therapy for acute decompensated heart failure (ADHF). This patient presents with classic signs of volume overload and left ventricular failure, including an S3 gallop, elevated jugular venous pressure, and bibasilar crackles. The wheezing is a result of peribronchial edema (often referred to as 'cardiac asthma'). Intravenous furosemide rapidly decreases preload and pulmonary congestion, improving oxygenation and respiratory distress.

Adım Adım Çözüm

Analyze the patient's vital signs and physical examination findings.

The patient has hypoxia, hypertension, elevated jugular venous pressure (JVP), an S3 gallop, crackles, and wheezing.

Identifying the constellation of physical signs is necessary to differentiate the cause of acute dyspnea.

Differentiate between a primary pulmonary process and a cardiac process.

Despite the smoking history and wheezing, the presence of JVD, an S3 gallop, and bibasilar crackles confirms acute decompensated heart failure (ADHF) causing 'cardiac asthma'.

Wheezing can occur in ADHF due to peribronchial edema, which often misleads clinicians toward a COPD diagnosis.

Select the most appropriate initial management for the confirmed diagnosis.

Intravenous loop diuretics (e.g., furosemide) are chosen.

Loop diuretics rapidly reduce intravascular volume and left ventricular preload, directly relieving pulmonary edema and hypoxia.

Anahtar Kavram

Differentiation and acute management of acute decompensated heart failure (ADHF) presenting as cardiac asthma.

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Soru

Cevap

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Anahtar Kavram

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