A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath. Two days ago, she choked while having tea and doughnuts and almost lost consciousness. Her son performed the Heimlich maneuver. The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care. Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence. She is allergic to penicillin (anaphylaxis) . Her temperature is 38.9 C (102 F) , blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen. Auscultation of the chest shows crackles at the right lung base. The heart sounds are regular. There is no jugular venous distension. The abdomen is soft, nontender, and nondistended. There is no peripheral edema. Laboratory results are as follows: A portable chest x-ray shows a right lower-lobe infiltrate.
Item 1 of 4
Which of the following is the most appropriate next step in management of this patient?

Question

A 74-year-old woman is brought to the emergency department with fever, chills, and shortness of breath. Two days ago, she choked while having tea and doughnuts and almost lost consciousness. Her son performed the Heimlich maneuver. The patient has advanced Alzheimer dementia, and her son is her health care proxy and primary caregiver; her 73-year-old husband also participates in her care. Her other medical problems include hypertension, hyperlipidemia, coronary heart disease, ischemic stroke with mild residual right hemiparesis, history of heme-positive stools, and urine incontinence. She is allergic to penicillin (anaphylaxis) . Her temperature is 38.9 C (102 F) , blood pressure is 120/80 mm Hg, pulse is 92/min, and respirations are 24/min. Pulse oxymetry shows 89% on room air and 94% on 40% facemask oxygen. Auscultation of the chest shows crackles at the right lung base. The heart sounds are regular. There is no jugular venous distension. The abdomen is soft, nontender, and nondistended. There is no peripheral edema. Laboratory results are as follows:

A portable chest x-ray shows a right lower-lobe infiltrate.
Item 1 of 4
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfd9_6ac4_8f63_ab1c77ed21c1_MD0005_00 The patient's clinical features and the chronology of events are highly suggestive of aspiration pneumonia. This condition is due to an infection of the lung parenchyma by microbes from the oral cavity, commonly gram-positive cocci, gram-negative rods, and anaerobes (polymicrobial). Patients typically present 1-5 days following an aspiration episode with respiratory difficulty, cough, sputum, fever, and chills. Clindamycin has excellent activity against gram-positive cocci and anaerobes; it is usually the first-line drug as it is inexpensive, widely available, and associated with a low rate of methicillin-resistant Staphylococcus aureus superinfection. A combination beta-lactam and beta-lactamase inhibitor would be another option, but this patient has a penicillin allergy. Given her age, hypoxia, and comorbidities, she needs to be admitted to the hospital for management. It is important to differentiate aspiration pneumonitis from aspiration pneumonia. Aspiration pneumonitis is a chemical injury with inflammation of lung parenchyma due to the inhalation of foreign materials such as gastric contents (Mendelson's syndrome). Patients usually have a history of depressed level of consciousness and a witnessed vomiting or aspiration event. Respiratory distress occurs 2-5 hours after an aspiration event, and there are generally no features of infection. Treatment is supportive (without antibiotics). (Choice B) Corticosteroids are not indicated in aspiration pneumonia. In addition, this patient is not wheezing and has no asthma or any other chronic respiratory condition for which steroids would be indicated. (Choice C) There is no evidence of endocarditis suggesting the need for an echocardiogram at this point. Blood cultures are sometimes obtained in patients with pneumonia but are not always necessary. They are recommended if the patient is being admitted to the intensive care unit or in the setting of cavitary lesions, pleural effusions, leukopenia, severe liver disease, or certain immune deficiencies. endocarditis (Choice D) CT scan could be performed to further evaluate the lung infiltrates, but it is not required in this patient at this stage as the clinical presentation and chest x-ray are sufficient to diagnose and initiate treatment for her condition. (Choice E) Azithromycin is not effective in the treatment of aspiration pneumonia, and adequate sputum samples are difficult to obtain and not always indicated in elderly, demented patients. Educational objective: Aspiration pneumonia should be suspected in any patient with a recent history of foreign body aspiration, cough, sputum, and fever. The treatment is clindamycin or combination beta-lactam with beta-lactamase inhibitor. Aspiration pneumonitis should be suspected in patients with depressed level of consciousness, a history of vomiting, and respiratory distress shortly after an aspiration event. There are generally no features of infection, and treatment is supportive (without antibiotics). References: Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. (http://www.ncbi.nlm.nih.gov/pubmed/17278083) Reappraisal of clindamycin IV monotherapy for treatment of mild-to-moderate aspiration pneumonia in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/15821205)

A 74-Year-Old Woman Is Brought to the Emergency Department with Fever