A 78-year-old woman is brought to the emergency department by her neighbor due to cough, f… — USMLE Step 3

A $78$ -year-old woman is brought to the emergency department by her neighbor due to cough, fever, and generalized weakness. The neighbor found the patient on the floor of her apartment, stating she had fallen $12$ hours earlier when trying to get to the bathroom and was too weak to get back up. The patient has a $3$ -day history of a productive cough. Medical history includes hypertension, osteoporosis, and moderate osteoarthritis of the knees. She lives alone.

On physical examination, temperature is $38.2^\circ\text{C}$ ( $100.8^\circ\text{F}$ ), pulse is $92$ /min, blood pressure is $135/85$ mm Hg, and respirations are $20$ /min. Pulse oximetry shows $95\%$ on room air. She is alert and oriented to person, place, and time. Lung auscultation reveals crackles in the left lower lobe. There is no evidence of trauma or fracture from the fall, but she exhibits profound generalized weakness. Physical therapy evaluation in the emergency department demonstrates she is currently unable to ambulate and requires moderate assistance from two people to transfer from the bed to a chair.

Laboratory studies show:
Leukocyte count: $11,500/\text{mm}^3$
Blood urea nitrogen: $16$ mg/dL
Serum creatinine: $0.9$ mg/dL

A chest radiograph confirms a left lower lobe consolidation. Intravenous hydration and empiric oral antibiotics are initiated.

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

A
Discharge home with oral antibiotics and primary care follow-up
B
Discharge home with home health care nursing and physical therapy
Admission to the general medical floorAnswer
D
Admission to a step-down (telemetry) unit
E
Admission to the intensive care unit

Answer

Admission to the general medical floor

The correct disposition is admission to the general medical floor. This patient presents with community-acquired pneumonia. According to the CURB-65 severity score (Confusion, Uremia, Respiratory rate, Blood pressure, age

\geq 65

), she scores

1

point solely for her age (

78

years). A score of

0

1

indicates a low mortality risk, and these patients are generally recommended for outpatient treatment. However, objective scoring systems must always be synthesized with the patient's functional capacity, mobility, and social support. This patient experienced a prolonged 12-hour fall, requires two-person assistance for transfers, and lives alone. Therefore, she is functionally unsafe to return home. She requires admission to the general medical floor to ensure her safety while a multidisciplinary team coordinates a safe post-acute disposition, which will likely involve placement in a skilled nursing facility for rehabilitation.

Step-by-Step Solution

Calculate the objective pneumonia severity risk score.

The patient's CURB-65 score is

1

(she receives

1

point for age

\geq 65

years, but has no confusion, normal BUN, normal respiratory rate, and normal blood pressure).

To determine the baseline recommended level of care based strictly on medical mortality risk, which suggests outpatient management for a score of

0

1

Assess the patient's functional capacity and social determinants of health.

The patient lives alone, recently suffered a prolonged lie on the floor after a fall, and currently requires two-person assistance for basic transfers.

To evaluate if the patient can safely manage her condition, medications, and activities of daily living in an outpatient setting.

Synthesize the medical severity and functional assessment to determine the final disposition.

Although she qualifies for outpatient therapy medically, her profound physical deficits mandate hospital admission.

To ensure patient safety and facilitate a multidisciplinary evaluation (physical therapy, social work) for appropriate post-acute placement (e.g., a skilled nursing facility).

Key Concept

Clinical disposition decisions must synthesize objective medical severity scores (e.g., CURB-65) with a patient's functional capacity and social support; patients who are medically suitable for discharge must be admitted if their physical limitations and home environment render outpatient management unsafe.

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