A Patient Presents To ED Complaining Of Shortness of Breath And Cough Of 10 Days Duration

A 33-year-old male presents to the ED complaining of shortness of breath and cough of 10 days duration. He must sleep in a chair due to orthopnea. He has severe fatigue and a mild, diffuse headache. Four days ago, he was seen in an urgent care clinic and diagnosed with bronchitis. He reports no medical problems or surgeries. He quit smoking 1 year ago and denies alcohol and drug use. He has a strong family history of hypertension. The review of systems is otherwise negative.
On physical examination, his vitals are T 36.8◦C, P 104, RR 16, and BP 200/118. There are bibasilar
crackles with dullness to percussion at the lung bases. The heart, abdomen, and extremities are unremarkable. His chest x-ray shows cardiomegaly, mild CHF, and bilateral small pleural effusions. An ECG shows sinus tachycardia with left atrial enlargement and left ventricular hypertrophy. Lab results: troponin-T negative, hemoglobin 9.1 g/dL, WBC count and platelets normal, Na 136 mEq/L, K 4.4 mEq/L, Cl 96 mEq/L, HCO3 19 mEq/L, BUN 108 mg/dL, Cr 11.9 mg/dL, glucose 104 mg/dL, calcium 7.8 mg/dL, albumin 4.0 g/dL.

Which of the following is the most appropriate next step?
A) Prescribe levofloxacin and discharge patient with follow-up the next day.
B) Prescribe furosemide and discharge patient with follow-up the next day.
C) Administer a bolus of normal saline intravenously and admit the patient.
D) Administer furosemide intravenously and admit the patient.
E) Perform thoracentesis for diagnostic purposes.

Answer And Discussion:
The correct answer is “D.”Administer furosemide intravenously and admit the patient.

The proper disposition of this patient is the hospital. His uremia is quite severe, and he is symptomatic from his renal failure. He needs further diagnostic tests and requires further monitoring.
He has signs and symptoms of volume overload, and he may yet respond to loop diuretics. A trial of
IV furosemide is reasonable. Even if it doesn’t cause a diuresis, furosemide can decrease pulmonary capillary wedge pressure.

The initial diagnosis of bronchitis was most likely erroneous and switching to another antibiotic will only perpetuate that error.

As he is volume overloaded, you certainly do not want to administer more volume.

If you are willing to attribute his pleural effusions to volume overload due to kidney failure, a thoracentesis is not necessary.