Examkin

Soru

Zorluk: KolayCardiovascular System

An emergency department physician is evaluating a 70-year-old female who complains of worsening shortness of breath over the past three days. The patient states she has been waking up in the middle of the night gasping for air and has had to sleep in a recliner chair. Her medical history includes hypertension, type 2 diabetes mellitus, and coronary artery disease. Vital signs show a blood pressure of 158/92 mm Hg, heart rate of 110/min, and respiratory rate of 24/min. Physical examination reveals elevated jugular venous pressure, an S3 heart sound, and bilateral crackles at the lung bases. Trace pitting edema is noted in the lower extremities. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

  1. Intravenous furosemideCevap
  2. B
    Inhaled albuterol
  3. C
    Intravenous ceftriaxone
  4. D
    Oral metoprolol
  5. E
    Intravenous normal saline

Cevap

Intravenous furosemide
The correct intervention is intravenous furosemide. This patient's presentation of orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, an S3 gallop, and bibasilar crackles is a textbook description of acute decompensated heart failure (ADHF) with significant volume overload. In the acute setting, the most critical intervention is to offload the heart and reduce pulmonary congestion. Intravenous loop diuretics accomplish this by rapidly promoting diuresis and inducing a degree of venodilation, which lowers cardiac preload and improves respiratory symptoms.

Adım Adım Çözüm

1
Analyze the patient's presenting symptoms and physical exam findings.
The patient has orthopnea, paroxysmal nocturnal dyspnea, elevated jugular venous pressure, an S3 gallop, and bibasilar crackles.
Identifying the clinical syndrome helps differentiate between cardiac, pulmonary, and infectious causes of dyspnea.
2
Diagnose the underlying condition.
The findings are classic for acute decompensated heart failure (ADHF) characterized by left and right-sided volume overload.
An S3 gallop and elevated jugular venous pressure are highly specific signs for heart failure exacerbation rather than COPD or pneumonia.
3
Determine the most appropriate initial pharmacological treatment.
Select an intravenous loop diuretic (e.g., furosemide).
Loop diuretics provide rapid diuresis and mild venodilation, directly addressing the underlying mechanism of pulmonary congestion by reducing preload.

Anahtar Kavram

The initial management of acute decompensated heart failure relies on rapid preload and volume reduction using intravenous loop diuretics.

Alternatif Yöntem

Intravenous nitroglycerin is an excellent alternative or adjunct therapy for this patient. It acts as a rapid venodilator to reduce preload, and is particularly useful in patients with acute decompensated heart failure presenting with hypertension.
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Cardiovascular System

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