A 55-year-old woman is evaluated in the emergency department due to a 4-day history of pro… — USMLE Step 2 CK

A 55-year-old woman is evaluated in the emergency department due to a 4-day history of progressively worsening shortness of breath. She reports that her baseline chronic morning cough has increased in frequency and is now producing thick, yellow sputum. She has a 35-pack-year smoking history. Her temperature is $37.5^\circ\text{C}$ ( $99.5^\circ\text{F}$ ), blood pressure is $132/82\text{ mm Hg}$ , pulse is $96/\text{min}$ , and respiratory rate is $22/\text{min}$ . Pulse oximetry on room air is $92\%$ . Physical examination reveals a prolonged expiratory phase with diffuse bilateral expiratory wheezing. Jugular venous pressure is $6\text{ cm H}_2\text{O}$ . There is no peripheral edema. Chest radiograph shows hyperinflated lung fields with flattened diaphragms but no focal consolidation or pulmonary edema. Arterial blood gas analysis on room air reveals:

$\text{pH}$ : $7.37$
$\text{pCO}_2$ : $50\text{ mm Hg}$
$\text{pO}_2$ : $66\text{ mm Hg}$
$\text{HCO}_3^-$ : $28\text{ mEq/L}$

Which of the following is the most appropriate initial pharmacological management for this patient?

Inhaled albuterol, oral prednisone, and oral azithromycinAnswer
B
Intravenous furosemide and sublingual nitroglycerin
C
Intravenous vancomycin and piperacillin-tazobactam
D
Intravenous sodium bicarbonate
E
Intravenous metoprolol and oral aspirin

Answer

Inhaled albuterol, oral prednisone, and oral azithromycin

The correct answer provides the standard triad of therapy for an acute exacerbation of chronic obstructive pulmonary disease (COPD) that meets the criteria for antibiotic use. This patient exhibits the three cardinal symptoms of a COPD exacerbation: increased dyspnea, increased sputum volume, and increased sputum purulence. The presence of these three symptoms strongly indicates the need for an antibiotic, typically a macrolide (e.g., azithromycin) or tetracycline. Additionally, short-acting bronchodilators (e.g., albuterol) and systemic corticosteroids (e.g., oral prednisone) are the mainstay treatments to reduce airway inflammation and relieve acute bronchospasm. The arterial blood gas shows a fully compensated chronic respiratory acidosis without severe acute acidemia (pH > 7.35), indicating that noninvasive positive pressure ventilation is not currently required.

Step-by-Step Solution

Analyze the patient's clinical presentation.

The patient has increased dyspnea, increased sputum volume, and purulent yellow sputum.

These findings represent the three cardinal signs of an acute exacerbation of chronic obstructive pulmonary disease (COPD).

Evaluate the physical exam, imaging, and lab data to rule out alternative diagnoses.

The normal jugular venous pressure, clear chest radiograph (no edema), and absence of severe acidemia (pH is 7.37) rule out acute decompensated heart failure and the immediate need for noninvasive positive pressure ventilation.

To ensure the chosen therapy targets the correct pathophysiology and severity level without causing harm.

Determine the appropriate pharmacological interventions.

The standard triad of short-acting bronchodilators, systemic corticosteroids, and a narrow-spectrum macrolide antibiotic is indicated.

Bronchodilators and steroids reduce airway inflammation, while antibiotics are indicated specifically when all three cardinal symptoms (including purulence) are present.

Key Concept

The initial outpatient or emergency department management of an uncomplicated acute COPD exacerbation with cardinal symptoms includes short-acting bronchodilators, systemic corticosteroids, and targeted narrow-spectrum antibiotics.

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic