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Zorluk: OrtaCardiovascular System

A 71-year-old retired teacher with a significant smoking history and essential hypertension is evaluated in the emergency department for worsening respiratory distress over the past 48 hours. She describes a sensation of 'drowning' when she tries to sleep and has resorted to sitting upright in a chair overnight. She has a cough producing frothy sputum. Current medications include lisinopril and hydrochlorothiazide. Her temperature is 37.0°C (98.6°F), blood pressure is 172/98 mmHg, pulse is 112/min, and respiratory rate is 26/min. Oxygen saturation is 88% on room air. Physical examination reveals prominent jugular veins when sitting at a 45-degree angle. Lung auscultation yields diffuse expiratory wheezing and prominent crackles in the lower lung fields bilaterally. Cardiac examination reveals a regular tachycardia with a distinct third heart sound (S3). A chest radiograph demonstrates bilateral interstitial infiltrates, prominent superior pulmonary vessels, and an enlarged cardiac silhouette. Which of the following is the most appropriate initial pharmacotherapy for this patient?

  1. Intravenous furosemideCevap
  2. B
    Nebulized albuterol and ipratropium
  3. C
    Intravenous methylprednisolone
  4. D
    Intravenous levofloxacin
  5. E
    Intravenous metoprolol

Cevap

Intravenous furosemide
The correct answer is the administration of an intravenous loop diuretic because this patient is experiencing acute decompensated heart failure (ADHF). The classic signs of left and right heart failure present here include orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, an S3 gallop, and characteristic chest radiograph findings (cardiomegaly, interstitial infiltrates). The diffuse wheezing is known as 'cardiac asthma,' caused by peribronchial edema compressing the airways. Intravenous furosemide rapidly decreases intravascular volume and provides immediate venodilation, which quickly reduces pulmonary capillary wedge pressure and improves dyspnea.

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1
Analyze the patient's presenting symptoms and vital signs.
The patient has orthopnea, paroxysmal nocturnal dyspnea, hypertension, tachycardia, and hypoxemia.
These findings suggest a severe cardiopulmonary process with significant respiratory compromise.
2
Interpret the physical examination and imaging findings.
Elevated jugular venous pressure, an S3 gallop, crackles, wheezing, and a chest radiograph showing cardiomegaly with interstitial infiltrates.
These signs confirm fluid overload and left ventricular failure, differentiating the presentation from a primary pulmonary disease.
3
Determine the correct diagnosis.
Acute decompensated heart failure (ADHF) presenting with 'cardiac asthma'.
The wheezing is secondary to peribronchial edema rather than primary bronchospasm from COPD.
4
Select the most appropriate initial management step.
Intravenous loop diuretics (e.g., furosemide) should be administered.
Loop diuretics provide rapid venodilation and subsequent diuresis to relieve pulmonary congestion.

Anahtar Kavram

Patients with acute decompensated heart failure can present with wheezing (cardiac asthma) due to peribronchial edema. The presence of an S3 gallop, elevated jugular venous pressure, and cardiomegaly on imaging differentiates this from a COPD exacerbation and dictates treatment with intravenous loop diuretics.
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Cardiovascular System

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