A 54-year-old male with a past medical history of type 2 diabetes mellitus comes to the emergency department complaining of shortness of breath. His blood pressure is 146/92 mmHg, respiratory rate is 26/min, and oxygen saturation is 87% on room air. Cardiac auscultation findings over the apex are given below. Based on the physical findings, which of the following is the best initial therapy for this patient?

Question

A 54-year-old male with a past medical history of type 2 diabetes mellitus comes to the emergency department complaining of shortness of breath.  His blood pressure is 146/92 mmHg, respiratory rate is 26/min, and oxygen saturation is 87% on room air.  Cardiac auscultation findings over the apex are given below.  Based on the physical findings, which of the following is the best initial therapy for this patient?

Quizplus · Accepted Answer

In addition to hearing the normal S1 and S2 on auscultation, there is an extra sound occurring after S2 known as the third heart sound (S3). The presence of this additional heart sound produces a rhythm that has been described as sounding like "ken-tuc-KY", with the third syllable corresponding to the S3. The S3 is believed to result when inflow from the left atrium strikes blood that is already in the left ventricle, causing reverberation of blood between the left ventricular walls. Although this extra sound can be normal in younger individuals and well-trained athletes, its appearance later in life is often a sign of left ventricular failure. This patient has several signs consistent with left heart failure including shortness of breath, tachypnea, and hypoxemia. When combining these clinical findings with a S3, the most likely diagnosis is left ventricular failure, for which the most appropriate treatment at this time would be intravenous diuretics. (Choice A) Inhaled bronchodilators would be the appropriate treatment for patients suffering from an acute COPD or asthma exacerbation. However, such patients would present with wheezing on chest auscultation. (Choice B) Although patients with heart failure will benefit from beta-blockers in the long term, they are not as effective as diuretics at providing symptomatic benefits in the short term. (Choice C) Due to its negative inotropic effects, diltiazem is not beneficial in the treatment of patients with decompensated heart failure. (Choice E) A pericardiocentesis is indicated in some patients with a pericardial effusion, which is not associated with S3. Educational objective: The third heart sound (S3) is a low frequency diastolic sound heard just after S2 that is associated with left ventricular failure. Intravenous diuretics provide symptomatic benefits to patients with decompensated heart failure.

A 54-Year-Old Male with a Past Medical History of Type