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Zorluk: KolayPulmonary and Critical Care

A 72-year-old woman presents to an urgent care clinic with a 3-day history of progressively worsening shortness of breath. She reports waking up in the middle of the night feeling as though she is suffocating and has started using three pillows to sleep comfortably. Her medical history is significant for long-standing, poorly controlled hypertension and osteoarthritis. Her temperature is 37.0°C (98.6°F), blood pressure is 170/100 mm Hg, pulse is 110/min, and respiratory rate is 24/min. Pulse oximetry shows 92% on room air. Physical examination reveals distended neck veins 5 cm above the sternal angle. Cardiac auscultation demonstrates a third heart sound (S3). Lung auscultation reveals bilateral basilar crackles and diffuse expiratory wheezing. Bilateral 2+ pitting edema is present in the lower extremities. Which of the following is the most appropriate next step in management?

  1. Administration of intravenous furosemideCevap
  2. B
    Administration of nebulized albuterol
  3. C
    Initiation of intravenous methylprednisolone
  4. D
    Prescription of oral levofloxacin
  5. E
    Measurement of arterial blood gas

Cevap

The most appropriate next step in management is the administration of intravenous furosemide.
The patient's presentation of orthopnea, paroxysmal nocturnal dyspnea, jugular venous distension, an S3 gallop, basilar crackles, and lower extremity pitting edema strongly indicates acute decompensated heart failure (ADHF). Wheezing in this clinical context is known as 'cardiac asthma,' which is caused by peribronchial edema secondary to elevated left-sided heart pressures. The most appropriate initial treatment is immediate preload reduction and diuresis with an intravenous loop diuretic such as furosemide.

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1
Identify the primary clinical syndrome based on the patient's history and physical exam.
The patient has orthopnea, paroxysmal nocturnal dyspnea, jugular venous distension, an S3 gallop, basilar crackles, and peripheral edema.
These are classic, hallmark signs of volume overload and acute decompensated heart failure (ADHF).
2
Interpret the presence of diffuse expiratory wheezing in this specific context.
The wheezing represents 'cardiac asthma,' which is caused by peribronchial edema compressing the airways.
Distinguishing between ADHF and a primary obstructive pulmonary exacerbation (like COPD) is critical, as treating cardiac asthma with only bronchodilators ignores the underlying volume overload.
3
Select the most appropriate initial pharmacological therapy for the identified condition.
Intravenous loop diuretics (e.g., furosemide) should be administered immediately.
Loop diuretics rapidly reduce intravascular volume and preload, which quickly relieves pulmonary congestion and improves the patient's respiratory symptoms.

Anahtar Kavram

Differentiation of acute decompensated heart failure (cardiac asthma) from primary pulmonary exacerbations, and its initial management with loop diuretics.
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Konular

Pulmonary and Critical Care

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