As you arrive for your ED shift, an ambulance pulls in, carrying a patient struggling to breathe. The paramedics quickly brief you: your patient is a 76-year-old woman with a history of heart failure. She has been compliant with all of her medications but has had progressively worsening, difficult breathing. You notice coarse, wet-sounding lungs with poor air movement at the lung bases. You also notice significant pitting edema in both of her legs. She describes orthopnea and states that she has been sitting up in a chair to sleep for “a while.” When you examine her medications, you note that she is on a low dose of a beta blocker and an ACE inhibitor, despite a stated history of low blood pressure. She was also prescribed spironolactone and furosemide, and you can feel an implant under the skin of her left chest wall, which she confirms as an AICD. You attach your patient to the cardiac monitor and notice she is tachycardic, with a heart rate of 115 beats/min, and her blood pressure is 80/40 mm Hg. You wonder if she would be best treated with fluids or diuretics, and your medical student asks, “How do we decide?”
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