An emergency medical team brings a 67-year-old male to the acute care unit due to sudden-o… — USMLE Step 2 CK

An emergency medical team brings a 67-year-old male to the acute care unit due to sudden-onset respiratory distress that awakened him from sleep. The patient has a medical history significant for long-standing essential hypertension, diet-controlled type 2 diabetes mellitus, and a 40-pack-year history of cigarette smoking. On physical examination, his blood pressure is $165/92 \text{ mmHg}$ , pulse is $112/\text{min}$ , and respiratory rate is $26/\text{min}$ with an oxygen saturation of $88\%$ on room air. Jugular venous distention is prominent when sitting at a 45-degree angle. Cardiac auscultation reveals a regular tachycardia with a distinct $S_3$ gallop. Lung auscultation demonstrates bilateral basilar crackles along with scattered expiratory wheezes. Laboratory studies show:

Leukocyte count: $8,200/\text{mm}^3$
Arterial blood gas (room air):
$\text{pH}$ : $7.34$
$p\text{CO}_2$ : $48 \text{ mmHg}$
$\text{HCO}_3^-$ : $25 \text{ mEq/L}$

Thyroid panel:
$\text{TSH}$ : $1.2 \text{ } \mu\text{U/mL}$ (Normal: $0.4-4.0 \text{ } \mu\text{U/mL}$ )
Free $T_4$ : $0.7 \text{ ng/dL}$ (Normal: $0.9-1.7 \text{ ng/dL}$ )

Which of the following is the most appropriate initial pharmacological therapy for this patient's respiratory distress?

Intravenous furosemideCevap
B
Inhaled ipratropium and oral prednisone
C
Intravenous ceftriaxone and azithromycin
D
Intravenous sodium bicarbonate
E
Oral levothyroxine

Cevap

Intravenous furosemide is the most appropriate initial therapy.

The correct therapy relies on identifying that the patient is suffering from acute decompensated heart failure (ADHF). The presence of paroxysmal nocturnal dyspnea, jugular venous distention, an S3 gallop, and bibasilar crackles strongly supports ADHF. Intravenous furosemide (a loop diuretic) is the first-line therapy to decrease preload, thereby reducing pulmonary capillary hydrostatic pressure and relieving dyspnea.

Adım Adım Çözüm

Analyze the patient's presenting symptoms and physical exam findings.

The patient has orthopnea (awakened from sleep with dyspnea), jugular venous distention, an S3 gallop, and bibasilar crackles.

These are the cardinal signs of left and right-sided volume overload.

Differentiate the cause of dyspnea from other pulmonary conditions.

Although wheezing and a smoking history are present, the S3 gallop and elevated jugular venous pressure specifically confirm a cardiac etiology (acute decompensated heart failure) rather than a primary pulmonary etiology like COPD.

Accurate differentiation guides the correct emergency management pathway.

Determine the appropriate initial pharmacological intervention.

Intravenous loop diuretics (e.g., furosemide) are selected.

Loop diuretics rapidly reduce intravascular volume and preload, quickly relieving pulmonary congestion and improving oxygenation.

Anahtar Kavram

The clinical presentation of acute decompensated heart failure includes orthopnea, elevated jugular venous pressure, an S3 gallop, and pulmonary crackles, which should be treated initially with intravenous loop diuretics.

Tahmini Süre:1m 0s

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru