A 72-year-old man is brought to the emergency department by his daughter due to severe sho… — USMLE Step 2 CK

A 72-year-old man is brought to the emergency department by his daughter due to severe shortness of breath and an inability to lie flat in bed for the past $3$ days. He also reports a persistent nonproductive cough. His medical history is significant for chronic obstructive pulmonary disease (COPD), hypertension, stage 3 chronic kidney disease, and a nonfunctioning pituitary macroadenoma that was surgically resected $5$ years ago. His current medications include a daily tiotropium inhaler and amlodipine.

His temperature is $37.1^\circ$ C ( $98.8^\circ$ F), blood pressure is $165/95$ mm Hg, pulse is $102$ /min, and respiratory rate is $24$ /min. Pulse oximetry shows $88\%$ on room air. Physical examination reveals an elevated jugular venous pressure of $10$ cm H $_2$ O. Lung auscultation demonstrates bilateral crackles in the lower lung fields and a prolonged expiratory phase with scattered wheezes. Cardiac examination reveals a regular tachycardia and a prominent S $_3$ gallop. There is $2+$ pitting edema in the bilateral lower extremities.

Laboratory Study	Result	Reference Range
Leukocyte count	$7,500$ /mm $^3$	$4,000-11,000$ /mm $^3$
Serum sodium	$136$ mEq/L	$135-145$ mEq/L
Serum potassium	$4.2$ mEq/L	$3.5-5.0$ mEq/L
Serum bicarbonate	$18$ mEq/L	$22-28$ mEq/L
Blood urea nitrogen	$35$ mg/dL	$8-20$ mg/dL
Serum creatinine	$1.7$ mg/dL	$0.7-1.3$ mg/dL
Thyroid-stimulating hormone (TSH)	$1.5$ $\mu$ U/mL	$0.4-4.2$ $\mu$ U/mL
Free T4	$0.6$ ng/dL	$0.9-1.7$ ng/dL

Arterial Blood Gas (Room Air)	Result	Reference Range
pH	$7.37$	$7.35-7.45$
pCO $_2$	$32$ mm Hg	$35-45$ mm Hg
pO $_2$	$58$ mm Hg	$75-105$ mm Hg

A chest radiograph displays cardiomegaly, bilateral pleural effusions, and prominent interstitial markings without focal consolidation. Which of the following is the most appropriate next step in management for this patient?

Administer intravenous furosemideCevap
B
Administer nebulized albuterol and systemic glucocorticoids
C
Initiate empiric piperacillin-tazobactam and vancomycin
D
Initiate levothyroxine supplementation
E
Administer intravenous sodium bicarbonate

Cevap

The correct answer is to administer intravenous furosemide.

The patient's presentation of progressive orthopnea, elevated JVP, an S3 gallop, basilar crackles, and bilateral pitting edema is pathognomonic for acute decompensated heart failure (ADHF). The chest radiograph further supports this with cardiomegaly, pleural effusions, and interstitial edema. The most appropriate immediate next step in management is the administration of a loop diuretic, such as intravenous furosemide. This will rapidly decrease intravascular volume and right heart preload, which promptly relieves pulmonary congestion and improves the work of breathing.

Adım Adım Çözüm

Evaluate the clinical presentation and physical examination findings.

The patient has severe orthopnea, elevated jugular venous pressure, an S3 gallop, crackles, and peripheral edema.

These findings are hallmark signs of volume overload and acute decompensated heart failure (ADHF), overriding the diagnosis of a COPD exacerbation despite the presence of wheezing (cardiac asthma).

Analyze the laboratory and radiographic data to rule out competing diagnoses.

The chest radiograph confirms cardiomegaly and pulmonary edema without consolidation. The ABG shows a compensated metabolic acidosis with mild primary respiratory alkalosis, and thyroid labs show central hypothyroidism.

This confirms ADHF, rules out pneumonia (no consolidation/leukocytosis), and reveals underlying chronic issues that do not require immediate, life-saving acute intervention.

Select the most appropriate acute therapeutic intervention.

Intravenous furosemide is chosen.

Intravenous loop diuretics rapidly reduce intravascular volume and preload, quickly reversing pulmonary congestion and improving the patient's respiratory status.

Anahtar Kavram

Patients with acute decompensated heart failure can present with wheezing ('cardiac asthma'); management relies on rapid diuresis with intravenous loop diuretics, guided by signs of volume overload such as JVD, S3 gallop, and characteristic radiographic findings.

Tahmini Süre:1m 30s

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