A 73-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD) … — USMLE Step 2 CK

A 73-year-old woman with a history of severe chronic obstructive pulmonary disease (COPD) and ischemic cardiomyopathy (left ventricular ejection fraction of $35\%$ ) is brought to the emergency department by her son due to worsening shortness of breath for the past two days. She states that her cough has increased and her sputum has changed from white to thick green. She denies paroxysmal nocturnal dyspnea, orthopnea, or recent weight gain. Vital signs include temperature $37.9^\circ\text{C}$ ( $100.2^\circ\text{F}$ ), blood pressure $135/85\text{ mm Hg}$ , pulse $115/\text{min}$ , and respiratory rate $26/\text{min}$ . Oxygen saturation is $87\%$ on room air. Physical examination reveals use of accessory muscles of respiration. Lung auscultation demonstrates a prolonged expiratory phase with loud, bilateral polyphonic wheezes and no crackles. The jugular venous pressure is $6\text{ cm H}_2\text{O}$ (normal $<8\text{ cm H}_2\text{O}$ ). There is no peripheral edema. A chest radiograph reveals hyperinflated lungs but no cardiomegaly, pulmonary edema, or focal consolidation. Which of the following medication regimens is most appropriate for the initial management of this patient?

Inhaled albuterol-ipratropium, systemic glucocorticoids, and oral azithromycinCevap
B
Intravenous furosemide and intravenous nitroglycerin
C
Intravenous piperacillin-tazobactam and intravenous vancomycin
D
Intravenous sodium bicarbonate and intravenous magnesium sulfate
E
Intravenous metoprolol and continuous unfractionated heparin

Cevap

The most appropriate management is to initiate inhaled albuterol-ipratropium, systemic glucocorticoids, and an oral macrolide antibiotic such as azithromycin.

The correct answer provides the standard triad of pharmacological therapy for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). This patient presents with the three cardinal symptoms of AECOPD: increased dyspnea, increased cough, and increased sputum volume/purulence. Despite her history of ischemic cardiomyopathy, her physical examination (lack of crackles, normal jugular venous pressure, no peripheral edema) and chest radiograph (hyperinflated lungs without pulmonary edema) point away from acute decompensated heart failure. Therefore, the most appropriate initial management includes short-acting inhaled bronchodilators (albuterol-ipratropium) to relieve bronchospasm, systemic glucocorticoids to reduce airway inflammation, and antibiotics (such as oral azithromycin) to treat potential bacterial triggers.

Adım Adım Çözüm

Evaluate the patient's symptoms and history.

The patient has increased dyspnea, increased cough, and purulent sputum, representing the cardinal signs of an acute exacerbation of COPD (AECOPD).

Identifying the pattern of symptoms is necessary to form the primary differential diagnosis.

Differentiate between AECOPD and acute decompensated heart failure (ADHF).

Despite a history of cardiomyopathy, the absence of orthopnea, normal jugular venous pressure, absence of crackles, and lack of pulmonary edema on the chest radiograph strongly point away from ADHF.

Patients with multiple comorbidities must be carefully evaluated to ensure the correct acute pathology is treated.

Select the appropriate pharmacotherapy for the confirmed diagnosis of AECOPD.

Standard initial treatment includes short-acting bronchodilators, systemic glucocorticoids, and antibiotics (due to the presence of purulent sputum).

This triad addresses bronchospasm, airway inflammation, and potential bacterial infection triggering the exacerbation.

Anahtar Kavram

The diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) relies on identifying cardinal symptoms (dyspnea, cough, sputum purulence) and differentiating it from acute decompensated heart failure; standard initial management requires short-acting bronchodilators, systemic glucocorticoids, and antibiotics.

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