A 73-year-old man is brought to the emergency department by his son due to a 3-day history… — USMLE Step 3

A 73-year-old man is brought to the emergency department by his son due to a 3-day history of progressively worsening productive cough, subjective fevers, and confusion. The son notes that the patient has been disoriented since yesterday and has not been eating or drinking. Medical history is significant for hypertension and benign prostatic hyperplasia. On triage, his temperature is $38.9^\circ\text{C}$ ( $102.0^\circ\text{F}$ ), blood pressure is $86/54\text{ mmHg}$ , pulse is $118/\text{min}$ , and respiratory rate is $32/\text{min}$ . Pulse oximetry shows $88\%$ on room air. On physical examination, the patient is lethargic and oriented only to person. Coarse crackles are heard over the right lower posterior lung fields. Laboratory results show a leukocyte count of $16,500/\text{mm}^3$ , a blood urea nitrogen level of $34\text{ mg/dL}$ , and a creatinine level of $1.5\text{ mg/dL}$ . Chest radiography reveals a dense consolidation in the right lower lobe. Which of the following is the most appropriate disposition for this patient?

A
Discharge home with a prescription for oral levofloxacin and close outpatient follow-up
B
Admit to an emergency department observation unit for 24 hours of intravenous fluid resuscitation
C
Admit to a general medical ward with continuous telemetry and intravenous antibiotics
Admit to the intensive care unit for advanced hemodynamic and respiratory supportAnswer
E
Keep the patient in the emergency department pending final blood and sputum culture results

Answer

Admit to the intensive care unit for advanced hemodynamic and respiratory support

The correct answer is to admit the patient to the intensive care unit. This patient presents with severe community-acquired pneumonia. Determining the appropriate disposition requires objective risk stratification, commonly achieved using the CURB-65 score. This scoring system assigns one point for each of the following: Confusion, Uremia (BUN > 19 mg/dL), Respiratory rate >= 30/min, Blood pressure (systolic < 90 mmHg or diastolic <= 60 mmHg), and Age >= 65 years. This patient meets all five criteria, yielding a maximum score of 5. Patients with a score of 0-1 can typically be treated as outpatients, a score of 2 warrants admission to a general medical ward, and a score of 3-5 indicates severe illness. Specifically, a score of 4 or 5 carries a high short-term mortality risk and mandates direct admission to the intensive care unit for aggressive hemodynamic and respiratory management.

Step-by-Step Solution

Identify the patient's primary diagnosis and calculate illness severity.

The patient has community-acquired pneumonia (CAP). Applying the CURB-65 score yields 5 points: Confusion (1), Uremia > 19 mg/dL (1), Respiratory rate >= 30/min (1), Blood pressure < 90/60 mmHg (1), and Age >= 65 (1).

Risk stratification scores are essential for determining the appropriate level of care and disposition for patients presenting with acute infectious processes like CAP.

Match the calculated severity score to the recommended care setting.

A CURB-65 score of 4 or 5 indicates a high risk of mortality (15-40%) and strongly recommends intensive care unit (ICU) admission.

Patients with maximum severity scores frequently require aggressive interventions such as mechanical ventilation or vasopressor support, which can only be provided in an ICU setting.

Key Concept

Patients presenting with community-acquired pneumonia should be risk-stratified using tools like the CURB-65 score; scores of 3 or higher warrant hospitalization, and scores of 4 to 5 mandate intensive care unit admission.

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic