A 68-year-old man comes to the emergency department complaining of worsening shortness of … — USMLE Step 2 CK

A 68-year-old man comes to the emergency department complaining of worsening shortness of breath, a persistent nonproductive cough, and swelling in his legs over the past 4 days. He has a 40-pack-year smoking history and a medical history of hypertension, hyperlipidemia, and type 2 diabetes mellitus. His current medications include amlodipine, lisinopril, atorvastatin, and metformin. His temperature is $37.1^\circ\text{C}$ ( $98.8^\circ\text{F}$ ), blood pressure is $162/92\text{ mmHg}$ , pulse is $106/\text{min}$ , and respirations are $24/\text{min}$ . Pulse oximetry shows an oxygen saturation of $92\%$ on room air. Physical examination reveals a patient in mild respiratory distress using accessory muscles of respiration. Jugular venous pressure is elevated at $12\text{ cm H}_2\text{O}$ . Lung auscultation reveals bilateral diffuse expiratory wheezes and dullness to percussion at both bases. Cardiac examination shows a regular rhythm, tachycardia, and a third heart sound (S3). Trace bilateral pitting edema is present up to the ankles. An electrocardiogram shows sinus tachycardia with no acute ischemic changes. Which of the following is the most appropriate initial therapy for this patient's current condition?

Intravenous furosemideCevap
B
Inhaled albuterol and oral prednisone
C
Intravenous metoprolol
D
Oral azithromycin
E
Inhaled tiotropium

Cevap

Intravenous furosemide

This patient presents with signs and symptoms of acute decompensated heart failure (ADHF), including progressive dyspnea, elevated jugular venous pressure, an S3 gallop, and peripheral edema. The presence of expiratory wheezes in this context is often referred to as 'cardiac asthma.' This occurs because increased pulmonary capillary hydrostatic pressure leads to fluid transudation into the pulmonary interstitium, causing peribronchial edema and narrowing of the small airways. The dullness to percussion at the lung bases suggests the presence of bilateral pleural effusions, another classic sign of ADHF. The most appropriate initial management for ADHF with signs of severe volume overload is an intravenous loop diuretic, such as furosemide, which rapidly reduces intravascular volume and relieves pulmonary congestion.

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Analyze the patient's risk factors and presenting symptoms.

The patient has progressive dyspnea, nonproductive cough, and leg swelling. He has risk factors for both cardiovascular disease (hypertension, diabetes) and pulmonary disease (40-pack-year smoking history).

Establishing the differential diagnosis between acute decompensated heart failure (ADHF) and chronic obstructive pulmonary disease (COPD) exacerbation is necessary.

Evaluate the physical examination findings.

Elevated jugular venous pressure, an S3 gallop, dullness to percussion at the lung bases (indicating pleural effusions), and lower extremity pitting edema are present.

These findings strongly point toward volume overload and biventricular heart failure, distinguishing the presentation from primary lung disease despite the presence of wheezing (cardiac asthma).

Determine the most appropriate initial management for the confirmed diagnosis.

Intravenous loop diuretics (e.g., furosemide) should be administered.

Loop diuretics provide rapid diuresis and mild venodilation, which decreases preload, resolving pulmonary edema and relieving respiratory distress in ADHF.

Anahtar Kavram

Differentiating acute decompensated heart failure ('cardiac asthma') from a COPD exacerbation based on physical exam findings (S3 gallop, elevated jugular venous pressure) is critical for selecting the correct initial therapy of intravenous loop diuretics.

Soru

Cevap

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Anahtar Kavram

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