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Zorluk: KolayPulmonary and Critical Care

An ambulance brings a 71-year-old male to the emergency department due to severe shortness of breath that awoke him from sleep. He has a known medical background of chronic obstructive pulmonary disease and ischemic heart failure with a reduced ejection fraction. Over the past three days, he has noted increasing difficulty breathing when lying flat and has had to sleep in a recliner chair. He denies fever, chills, or changes in sputum production. His temperature is 37.0∘C37.0^\circ\text{C} (98.6∘F98.6^\circ\text{F}), blood pressure is 170/95 mm Hg170/95\text{ mm Hg}, pulse is 115/min115/\text{min}, and respirations are 28/min28/\text{min}. Oxygen saturation is 86%86\% on room air. Examination reveals distended jugular veins when sitting at a 45-degree angle. Pulmonary auscultation demonstrates bilateral crackles up to the mid-lung fields without significant wheezing. Cardiac auscultation reveals a regular tachycardia with an S3 gallop. A bedside chest radiograph demonstrates an enlarged cardiac silhouette, prominent pulmonary vasculature, and bilateral pleural effusions. Which of the following is the most appropriate initial pharmacological intervention for this patient?

  1. Intravenous furosemideCevap
  2. B
    Inhaled albuterol and oral prednisone
  3. C
    Intravenous piperacillin-tazobactam
  4. D
    Intravenous sodium bicarbonate
  5. E
    Oral azithromycin

Cevap

Intravenous furosemide
The correct answer is intravenous furosemide because this patient is presenting with classic signs of acute decompensated heart failure (ADHF). Despite his history of chronic obstructive pulmonary disease (COPD), his symptoms of orthopnea, paroxysmal nocturnal dyspnea, jugular venous distention, an S3 gallop, and crackles on exam strongly indicate volume overload. The chest radiograph showing cardiomegaly, prominent vasculature, and pleural effusions confirms cardiogenic pulmonary edema. The primary treatment for ADHF with volume overload is intravenous loop diuretics (such as furosemide) to reduce preload and relieve pulmonary congestion.

Adım Adım Çözüm

1
Analyze the patient's presenting symptoms and history.
The patient has orthopnea, paroxysmal nocturnal dyspnea, and a history of both heart failure and COPD.
Identifying key symptoms helps differentiate between the patient's two underlying chronic diseases.
2
Evaluate the physical examination and imaging findings.
Findings include jugular venous distention, crackles, an S3 gallop, cardiomegaly, and pleural effusions, all without fever or prominent wheezing.
These specific signs strongly indicate volume overload and acute cardiogenic pulmonary edema.
3
Select the appropriate pharmacological intervention.
Intravenous furosemide is chosen to rapidly induce diuresis and relieve pulmonary congestion.
Loop diuretics are the standard of care for acute decompensated heart failure presenting with volume overload.

Anahtar Kavram

Patients presenting with acute decompensated heart failure (characterized by orthopnea, paroxysmal nocturnal dyspnea, JVD, an S3 gallop, and pulmonary crackles) require prompt diuresis with intravenous loop diuretics, even if they have a concurrent history of COPD.
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Pulmonary and Critical Care

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