A 64-year-old woman is brought to the emergency department by emergency medical services d… — USMLE Step 2 CK

A 64-year-old woman is brought to the emergency department by emergency medical services due to severe, worsening shortness of breath that began 24 hours ago. The patient has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$ , hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease (GOLD stage III). Her temperature is $37.2^\circ\text{C}$ ( $99.0^\circ\text{F}$ ), blood pressure is $170/95\text{ mm Hg}$ , pulse is $118/\text{min}$ , and respirations are $28/\text{min}$ . Pulse oximetry shows $86\%$ on room air. She appears in moderate respiratory distress and is using accessory muscles of respiration. Lung auscultation reveals prolonged expiration, diffuse expiratory wheezing, and bilateral crackles at the lung bases. Cardiovascular examination shows distant heart sounds, a normal S1 and S2, and a prominent S3 gallop. The jugular venous pressure is estimated at $13\text{ cm H}_2\text{O}$ . There is $2+$ bilateral lower extremity pitting edema.

Laboratory studies show:

Lab Test	Result	Reference Range
pH	$7.27$	$7.35 - 7.45$
pCO $_2$	$56\text{ mm Hg}$	$35 - 45\text{ mm Hg}$
pO $_2$	$55\text{ mm Hg}$	$75 - 105\text{ mm Hg}$
HCO $_3^-$	$25\text{ mEq/L}$	$22 - 28\text{ mEq/L}$
TSH	$1.2\text{ \mu U/mL}$	$0.4 - 4.0\text{ \mu U/mL}$
Free T4	$0.6\text{ ng/dL}$	$0.9 - 1.7\text{ ng/dL}$

Chest radiograph reveals cardiomegaly, bilateral pleural effusions, and cephalization of the pulmonary vasculature. Which of the following is the most appropriate next step in management?

Intravenous furosemide and noninvasive positive pressure ventilationCevap
B
Systemic corticosteroids and nebulized albuterol
C
Intravenous metoprolol
D
Intravenous sodium bicarbonate
E
Oral levothyroxine

Cevap

The most appropriate next step in management is to administer intravenous furosemide and noninvasive positive pressure ventilation.

The correct answer properly targets both the underlying volume overload and the acute respiratory distress. The patient's presentation of wheezing, an S3 gallop, elevated jugular venous pressure, and radiographic evidence of pulmonary edema is diagnostic of acute decompensated heart failure (ADHF). Intravenous loop diuretics are first-line for volume removal. Concurrently, noninvasive positive pressure ventilation (NPPV) is indicated for patients with ADHF who have severe dyspnea, hypoxia, or respiratory acidosis, as it decreases the work of breathing and favorably alters cardiopulmonary hemodynamics by reducing both preload and afterload.

Adım Adım Çözüm

Analyze the clinical presentation to differentiate between a chronic obstructive pulmonary disease exacerbation and acute decompensated heart failure.

The presence of a prominent S3 gallop, elevated jugular venous pressure, and cardiomegaly strongly points to acute decompensated heart failure rather than a primary pulmonary etiology.

Patients with a history of both heart failure and lung disease frequently present with overlapping symptoms like dyspnea and wheezing (cardiac asthma).

Evaluate the patient's hemodynamic and respiratory status using vital signs, physical exam, and laboratory data.

The patient is hypertensive, hypoxic, and has an acute respiratory acidosis (

pH\ 7.27

pCO_2\ 56\text{ mm Hg}

), indicating severe respiratory distress secondary to pulmonary edema.

Identifying the severity of the respiratory failure determines the urgency and modality of respiratory support needed.

Select the optimal initial therapeutic interventions for acute decompensated heart failure presenting with respiratory distress.

Intravenous loop diuretics (furosemide) and noninvasive positive pressure ventilation are selected.

Furosemide rapidly reduces volume overload, while noninvasive positive pressure ventilation decreases both right ventricular preload and left ventricular afterload, rapidly improving oxygenation without the need for immediate intubation.

Anahtar Kavram

Differentiating 'cardiac asthma' (acute decompensated heart failure) from a chronic obstructive pulmonary disease exacerbation is critical; management of acute heart failure with respiratory distress requires prompt administration of intravenous diuretics and noninvasive positive pressure ventilation.

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Cevap

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Anahtar Kavram

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