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Zorluk: KolayCardiovascular System

A 69-year-old woman is brought to the emergency department due to severe shortness of breath that awakened her from sleep 2 hours ago. She has a history of hypertension, type 2 diabetes mellitus, and a 40-pack-year smoking history. Her current medications include amlodipine and metformin. Her temperature is 36.8°C (98.2°F), blood pressure is 172/98 mm Hg, pulse is 115/min, and respirations are 26/min. Pulse oximetry is 89% on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. Cardiac auscultation reveals a regular tachycardia with a prominent S3 gallop. There is 1+ bilateral lower extremity pitting edema. Which of the following diagnostic findings is most likely to be present in this patient?

  1. Elevated serum B-type natriuretic peptide levelCevap
  2. B
    Flattened diaphragms and hyperlucent lung fields on chest radiograph
  3. C
    Decreased forced expiratory volume in 1 second to forced vital capacity ratio
  4. D
    Right ventricular dilation with normal left ventricular systolic function on echocardiography
  5. E
    Normal pulmonary capillary wedge pressure on right heart catheterization

Cevap

Elevated serum B-type natriuretic peptide level
The patient's presentation of sudden-onset dyspnea awakening her from sleep (paroxysmal nocturnal dyspnea), hypertension, jugular venous distention, basilar crackles, and an S3 gallop is highly characteristic of acute decompensated heart failure (ADHF). The diffuse wheezing is likely 'cardiac asthma' caused by perivascular and peribronchial edema narrowing the airways. B-type natriuretic peptide (BNP) is released from ventricular myocytes in response to increased stretch and wall tension. An elevated serum BNP level is strongly associated with ADHF and is an excellent diagnostic tool to differentiate cardiogenic pulmonary edema from primary pulmonary causes of dyspnea.

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1
Analyze the patient's presenting symptoms and vital signs.
The patient has acute-onset dyspnea, paroxysmal nocturnal dyspnea (awakening from sleep), hypertension, tachycardia, and hypoxia.
Identifying the acuity and characteristics of the respiratory distress helps narrow the differential diagnosis.
2
Interpret the physical examination findings.
Elevated jugular venous pressure, an S3 gallop, and bilateral basilar crackles indicate left ventricular volume overload, while wheezing represents 'cardiac asthma' secondary to peribronchial edema.
Specific physical exam signs, especially the S3 gallop, strongly differentiate acute decompensated heart failure from a primary pulmonary exacerbation.
3
Determine the most likely diagnostic finding based on the clinical diagnosis of acute decompensated heart failure.
An elevated serum B-type natriuretic peptide (BNP) level is expected.
BNP is secreted by the ventricles in response to volume expansion and pressure overload, serving as a highly sensitive marker for heart failure.

Anahtar Kavram

Clinical presentation and initial diagnostic evaluation of acute decompensated heart failure versus COPD exacerbation.
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Konular

Cardiovascular System

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