A 68-year-old patient with a history of heart failure presents with acute dyspnea, orthopnea, and bilateral crackles on lung auscultation. His blood pressure is 150/90 mmHg. Which medication is most appropriate as an initial treatment?

The correct answer to the question "A 68-year-old patient with a history of heart failure presents with acute dyspnea, orthopnea, and bilateral crackles on lung auscultation. His blood pressure is 150/90 mmHg. Which medication is most appropriate as an initial treatment?" is Option B: Furosemide.

The other options — A) Digoxin, C) Enalapril, D) Metoprolol — are incorrect for this USMLE Exam Prep question. As explained above: For acute decompensated heart failure with signs of fluid overload (dyspnea, crackles), loop diuretics like furosemide are the mainstay of initial treatment to reduce preload and alleviate symptoms.