WBR0453

Author	Neeraja Danda M.B.B.S
Exam Type	USMLE Step 2 CK
Main Category	Internal medicine
Sub Category	Cardiovascular
Prompt	A 38 year old female presents to the emergency room with sudden severe shortness of breath with respiratory rate of 35/min. Cardiopulmonary auscultation identifies apical rales in lungs, an S3 murmur and jugular venous distension 3 cm above the Angle of Louis .The patient reveals that for the past 3 months she has awoken short of breath several times during the night and sleeping with two pillows helps her rest. Her past medical history is significant for hypertension, hypothyroidism and myocardial infarction at the age of 35 . Her current medications are clopidogrel, atenolol, and atorvastatin . What is the best initial treatment?
Answer A	Digoxin
Answer A Explanation	Incorrect Digoxin is not useful in the acute setting. It is used when heart failure is associated with atrial arrhythmia .
Answer B	Nesiritide
Answer B Explanation	Incorrect Nesiritide is an intravenous form of atrial natriuretic peptide and is a weak diuretic, it has no use in acute treatment of heart failure.
Answer C	Intravenous furosemide
Answer C Explanation	Loop diuretic reduces preload thus relieves acute symptoms of heart failure.
Answer D	Echocardiography
Answer D Explanation	IncorrectEchocardiography is done to distinguish between systolic and diastolic dysfunctions. Echocardiography findings would not change the initial therapy of this patient.
Answer E	Synchronized cardioversion
Answer E Explanation	Incorrect Synchronized cardioversion is performed when arrhythmias are the reason for heart failure.
Right Answer	C
Explanation	The best initial therapy for heart failure is a loop diuretic to decrease preload. Reduced preload will relieve this patient’s acute symptoms . Educational Objective:The standard of care for the acute treatment of heart failure includes a loop diuretic such as furosemide, along with oxygen, morphine and nitrates. References:Page 83,84 Master the boards Step 2 CK second edition Educational Objective: References:
Approved	Yes
Keyword	Heart failure, preload, diuretic, Nesiritide
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