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Difficulty: EasyGeneral Internal Medicine

A 72-year-old man is brought to the emergency department by his son due to worsening shortness of breath, increased cough, and progressive lethargy over the past 48 hours. The son notes that the patient's baseline morning cough has been producing thick, yellowish sputum since yesterday. The patient has a history of severe chronic obstructive pulmonary disease (COPD) and hypertension. His temperature is 38.1°C (100.6°F), blood pressure is 134/82 mm Hg, pulse is 108/min, and respirations are 26/min. Pulse oximetry shows 88% on room air. Physical examination reveals an increased anteroposterior chest diameter. Lung auscultation demonstrates bilateral diffuse wheezing and a prolonged expiratory phase. There are no crackles, jugular venous distension, or lower extremity edema.

Laboratory testing shows:
Leukocyte count: 12,500/mm³
Thyroid-stimulating hormone (TSH): 2.5 µU/mL (normal: 0.5-5.0)
Free thyroxine (T4): 1.2 ng/dL (normal: 0.9-1.7)

Arterial blood gas on room air:
pH: 7.28
PaCO₂: 65 mm Hg
PaO₂: 55 mm Hg

Which of the following is the most appropriate initial pharmacological management?

  1. A
    Intravenous furosemide and sublingual nitroglycerin
  2. B
    Intravenous meropenem and vancomycin
  3. Inhaled short-acting bronchodilators, systemic glucocorticoids, and oral azithromycinAnswer
  4. D
    Intravenous sodium bicarbonate
  5. E
    Intravenous levothyroxine and hydrocortisone

Answer

Inhaled short-acting bronchodilators, systemic glucocorticoids, and oral azithromycin
This patient is experiencing an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), characterized by the three cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence. His lethargy and ABG findings (pH 7.28, PaCO2 65 mm Hg) indicate an acute respiratory acidosis due to progressive CO2 retention from severe airflow obstruction. The appropriate initial pharmacological management includes inhaled short-acting bronchodilators (albuterol/ipratropium) to relieve bronchospasm, systemic glucocorticoids to reduce airway inflammation, and a targeted antibiotic (such as oral azithromycin) to cover typical community-acquired respiratory pathogens (e.g., Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis).

Step-by-Step Solution

1
Identify the clinical syndrome based on the patient's symptoms.
The patient has increased dyspnea, increased cough, and purulent sputum, representing the three cardinal symptoms of an acute exacerbation of COPD.
Recognizing the cardinal symptoms establishes the primary diagnosis and directs specific therapy.
2
Rule out alternative causes of dyspnea and lethargy using exam and lab findings.
The absence of crackles, JVD, and edema makes heart failure unlikely. Normal TSH and T4 levels rule out myxedema coma as the cause of lethargy.
Overlapping presentations (like dyspnea in heart failure or lethargy in hypothyroidism) must be systematically excluded.
3
Interpret the acid-base status on the arterial blood gas.
The ABG shows an acute respiratory acidosis (pH 7.28, elevated PaCO2 65 mm Hg) secondary to poor ventilation, not a metabolic acidosis.
Accurate interpretation prevents inappropriate administration of buffering agents like sodium bicarbonate.
4
Select the appropriate pharmacologic package for the confirmed diagnosis.
The patient requires bronchodilators (for airflow), systemic glucocorticoids (for inflammation), and a targeted antibiotic like a macrolide (for infection).
This combination targets the bronchoconstriction, inflammation, and typical bacterial triggers of severe COPD exacerbations.

Key Concept

Management of acute exacerbations of COPD requires inhaled short-acting bronchodilators, systemic glucocorticoids, and appropriate targeted antibiotics when cardinal symptoms (increased dyspnea, sputum volume, and sputum purulence) are present.
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General Internal Medicine

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