Paramedics bring an 80-year-old woman to the resuscitation bay due to the acute onset of s… — USMLE Step 2 CK

Paramedics bring an 80-year-old woman to the resuscitation bay due to the acute onset of severe breathlessness. Her symptoms began suddenly about an hour ago while she was watching television. The patient has a known medical history of poorly controlled hypertension, hyperlipidemia, and stable angina. On assessment, she is coughing up frothy, pink-tinged sputum and appears highly anxious. Vital signs show a temperature of $36.8^\circ\text{C}$ ( $98.2^\circ\text{F}$ ), a blood pressure of $190/110\text{ mmHg}$ , a heart rate of $118/\text{min}$ , and a respiratory rate of $28/\text{min}$ . Her oxygen saturation is $84\%$ on room air. The physical examination is notable for prominent distention of the jugular veins when the patient is sitting upright. Cardiac auscultation reveals a regular tachycardia with a loud S4 gallop and no murmurs. Pulmonary auscultation yields coarse crackles heard throughout all lung fields bilaterally. Which of the following is the most appropriate initial pharmacologic therapy for this patient?

Intravenous furosemideCevap
B
Inhaled albuterol
C
Intravenous levofloxacin
D
Intravenous heparin
E
Intravenous sodium bicarbonate

Cevap

Intravenous furosemide

The patient's presentation of acute severe dyspnea, hypoxia, severe hypertension (

190/110\text{ mmHg}

), pink frothy sputum, jugular venous distention, an S4 gallop, and bilateral diffuse crackles is highly characteristic of acute decompensated heart failure (ADHF) presenting as flash pulmonary edema. In the setting of severe hypertension, the left ventricle faces acute pressure overload (afterload), leading to elevated left ventricular end-diastolic pressure. This pressure backs up into the left atrium and pulmonary circulation, causing transudation of fluid into the alveoli. The most appropriate initial pharmacologic therapy includes intravenous loop diuretics (such as furosemide) to rapidly decrease intravascular volume and reduce ventricular preload. Venodilators like intravenous nitroglycerin are also heavily indicated to rapidly reduce preload and afterload.

Adım Adım Çözüm

Identify the primary clinical syndrome based on the physical examination and vital signs.

The patient has severe hypertension, hypoxia, pink frothy sputum, jugular venous distention, an S4 gallop, and bilateral crackles, which collectively establish a diagnosis of acute decompensated heart failure (flash pulmonary edema).

Accurate diagnosis is required before initiating therapy, ensuring the differentiation of cardiogenic pulmonary edema from primary pulmonary pathologies.

Determine the most appropriate initial pharmacologic intervention for this syndrome.

Intravenous loop diuretics (e.g., furosemide) and vasodilators (e.g., nitroglycerin) are the mainstay of initial treatment.

Reducing intravascular volume and venous return (preload) rapidly lowers pulmonary capillary hydrostatic pressure, thereby alleviating alveolar edema and improving oxygenation.

Anahtar Kavram

Initial management of acute decompensated heart failure presenting as flash pulmonary edema involves aggressive preload reduction with intravenous loop diuretics and/or vasodilators.

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