The rapid response team is called to the surgical ward to assess a patient experiencing su… — USMLE Step 2 CK

The rapid response team is called to the surgical ward to assess a patient experiencing sudden respiratory distress. The patient is $48$ hours status-post an elective open ventral hernia repair. His past medical history is significant for severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy with a baseline left ventricular ejection fraction of $35\%$ . He complains of shortness of breath and a cough producing clear sputum. Vital signs reveal a temperature of $38.1^\circ\text{C}$ ( $100.6^\circ\text{F}$ ), blood pressure of $135/85\text{ mm Hg}$ , heart rate of $108\text{/min}$ , and respiratory rate of $26\text{/min}$ . Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination demonstrates a prolonged expiratory phase with diffuse bilateral wheezing. Jugular venous pressure is normal, crackles are absent, and there is no lower extremity edema. A bedside lung ultrasound reveals diffuse bilateral A-lines. A portable chest radiograph shows hyperinflated lung fields without focal consolidation or pleural effusion. A sputum culture obtained on the first postoperative day for a mild baseline cough is finalized today and reveals only normal respiratory flora. Based on this clinical presentation, which of the following are the most appropriate next steps in management? (Select all that apply)

Administration of systemic methylprednisoloneCevap
Administration of nebulized ipratropium and albuterolCevap
C
Administration of intravenous furosemide
D
Initiation of intravenous piperacillin-tazobactam
E
Lower extremity venous duplex ultrasonography

Cevap

The correct next steps in management are the administration of systemic methylprednisolone and nebulized ipratropium and albuterol.

The patient is experiencing a postoperative acute exacerbation of COPD, likely triggered by surgical stress and anesthesia. The classic presentation includes dyspnea, diffuse wheezing, and hypoxemia. Crucially, the bedside lung ultrasound showing A-lines confirms the absence of pulmonary edema, ruling out an acute heart failure decompensation despite his low ejection fraction. The standard of care for an acute COPD exacerbation requires short-acting bronchodilators (such as albuterol and ipratropium) to relieve bronchospasm, and systemic glucocorticoids (such as methylprednisolone) to reduce airway inflammation.

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Analyze the clinical syndrome and vital signs.

The patient has acute dyspnea, hypoxemia, wheezing, and hyperinflated lungs occurring

48

hours after surgery, superimposed on a history of both COPD and heart failure.

Identifying the primary cause of respiratory distress is critical for directing immediate postoperative therapy.

Differentiate between COPD exacerbation and acute decompensated heart failure.

The physical examination shows no signs of fluid overload, and the bedside ultrasound demonstrates A-lines (dry lungs) rather than B-lines (pulmonary edema).

Patients with multiple cardiopulmonary comorbidities require objective data (like POCUS) to distinguish the exact etiology of an exacerbation.

Evaluate the fever and infectious risk.

The low-grade fever fits the timeline for early postoperative inflammation or atelectasis. The clear sputum and normal flora on culture rule out a severe bacterial pneumonia.

This prevents the inappropriate administration of broad-spectrum antibiotics and unnecessary diagnostic workups for deep vein thrombosis.

Select the appropriate targeted interventions.

The diagnosis is an acute COPD exacerbation triggered by surgical stress, requiring short-acting bronchodilators and systemic steroids.

These medications directly address the acute bronchospasm and airway inflammation causing the hypoxemia.

Anahtar Kavram

Differentiation of postoperative respiratory distress using bedside ultrasound and clinical timelines to target appropriate therapy for COPD exacerbations.

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Cevap

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