A 70-year-old man comes to the emergency department due to severe shortness of breath that… — USMLE Step 2 CK

A $70$ -year-old man comes to the emergency department due to severe shortness of breath that has worsened over the past $24$ hours. He reports waking up multiple times during the night gasping for air and had to sleep sitting up in a recliner. His medical history includes chronic obstructive pulmonary disease (COPD), hypertension, and type 2 diabetes mellitus. His current medications include inhaled tiotropium, oral amlodipine, and metformin. His temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $168/94\text{ mm Hg}$ , pulse is $108/\text{min}$ , and respiratory rate is $26/\text{min}$ . Pulse oximetry is $88\%$ on room air. Physical examination reveals jugular venous distention to $11\text{ cm H}_2\text{O}$ above the sternal angle. Pulmonary auscultation reveals bibasilar crackles and diffuse expiratory wheezes. He has $2+$ pitting edema in both lower extremities. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

Intravenous furosemideCevap
B
Intravenous methylprednisolone and nebulized albuterol
C
Intravenous piperacillin-tazobactam
D
Oral azithromycin
E
Inhaled fluticasone

Cevap

Intravenous furosemide

The correct answer is intravenous furosemide because this patient is presenting with acute decompensated heart failure (ADHF). Despite his history of COPD, his symptoms of orthopnea (sleeping in a recliner) and paroxysmal nocturnal dyspnea (waking up gasping for air), combined with physical exam findings of elevated jugular venous pressure, bibasilar crackles, and lower extremity edema, strongly indicate severe volume overload. The wheezing he is experiencing is likely 'cardiac asthma,' which is caused by peribronchial edema secondary to pulmonary congestion. The most critical initial intervention is to reduce this volume overload with an intravenous loop diuretic, which rapidly improves pulmonary edema and respiratory mechanics.

Adım Adım Çözüm

Analyze the patient's presenting symptoms and physical exam findings.

The patient has orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, bibasilar crackles, and bilateral lower extremity edema.

These are the classic, defining clinical features of right- and left-sided volume overload.

Evaluate the wheezing in the context of the patient's medical history.

Although the patient has a history of COPD, the prominent signs of fluid overload suggest the wheezing is 'cardiac asthma'.

Peribronchial edema secondary to pulmonary congestion can cause airway narrowing and wheezing, which must be distinguished from a primary bronchospasm.

Determine the most appropriate initial management step.

The primary pathology is acute decompensated heart failure, requiring an intravenous loop diuretic.

Intravenous furosemide will induce rapid diuresis, reducing volume overload and alleviating the pulmonary edema causing his severe dyspnea.

Anahtar Kavram

Differentiating acute decompensated heart failure (ADHF) from a COPD exacerbation using clinical signs of volume overload, and treating ADHF with intravenous loop diuretics.

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