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Zorluk: KolayCardiovascular System

A 71-year-old woman is evaluated in the hospital during the night shift for acute-onset shortness of breath. She was admitted two days ago for acute pyelonephritis and has been receiving intravenous ceftriaxone alongside aggressive intravenous fluid resuscitation. Currently, she is visibly distressed and prefers to sit upright on the edge of the bed. Her temperature is 37.1°C (98.8°F), blood pressure is 158/92 mm Hg, pulse is 106/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals prominent jugular venous distention. Lung auscultation demonstrates bilateral crackles extending to the mid-lung fields, with no wheezing. Cardiac examination reveals a regular rhythm, normal S1 and S2, and a distinct third heart sound (S3). There is 2+ bilateral lower extremity pitting edema. Which of the following is the most appropriate next step in management of this patient's current symptoms?

  1. Intravenous furosemideCevap
  2. B
    Inhaled albuterol
  3. C
    Intravenous piperacillin-tazobactam
  4. D
    Intravenous normal saline bolus
  5. E
    Oral metoprolol

Cevap

Intravenous furosemide
The correct answer is intravenous furosemide. This patient is presenting with classic signs of acute decompensated heart failure (ADHF) precipitated by aggressive intravenous fluid resuscitation. The combination of orthopnea (preferring to sit upright), hypoxia, jugular venous distention, bibasilar crackles, a distinct S3 gallop, and lower extremity edema strongly points to severe volume overload leading to acute pulmonary edema. The most appropriate initial step in management for ADHF with signs of volume overload is the administration of an intravenous loop diuretic, such as furosemide. This rapidly decreases intravascular volume, reduces ventricular preload, and relieves pulmonary congestion, thereby improving the patient's respiratory status.

Adım Adım Çözüm

1
Analyze the clinical presentation and physical examination findings.
The patient presents with orthopnea, hypoxia, jugular venous distention, bibasilar crackles, and an S3 gallop after receiving aggressive intravenous fluids.
Identifying the constellation of signs and symptoms is necessary to determine the underlying etiology of the new-onset respiratory distress.
2
Establish the most likely diagnosis.
The clinical picture strongly indicates acute decompensated heart failure resulting from iatrogenic volume overload.
Distinguishing cardiogenic pulmonary edema from other causes of inpatient dyspnea directly guides the acute management.
3
Determine the most appropriate initial management.
Intravenous furosemide is selected as the initial treatment.
Loop diuretics are the first-line therapy to rapidly reduce intravascular volume and alleviate pulmonary congestion in acute decompensated heart failure.

Anahtar Kavram

Diagnosis and initial management of acute decompensated heart failure presenting with volume overload.
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Cardiovascular System

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