A 75-year-old man with moderate chronic obstructive lung disease is brought to the emergency department with acute onset of dyspnea that started this afternoon. He was discharged 2 days ago for a chronic obstructive pulmonary disease exacerbation treated with short-term noninvasive positive-pressure ventilation, corticosteroids, and antibiotics. He finished the oral antibiotics yesterday and has been nonambulatory since hospital discharge. He also complains of productive cough of whitish sputum and mild right-sided pleuritic chest pain. His other medical problems include hypertension, chronic lower-extremity edema with superficial ulcers, and severe right knee osteoarthritis.
His temperature is 37.2° C (99° F) , blood pressure is 120/73 mm Hg, pulse is 114/min, and respirations are 22/min. Pulse oximetry shows 89% on room air. Jugular venous pressure is estimated at 7 cm H₂O. Mild end-expiratory wheezing is heard bilaterally. There is bilateral, chronic-appearing edema of the lower extremities.
Laboratory results are as follows:

ECG shows sinus tachycardia with nonspecific T-wave changes. Chest x-ray shows hyperinflated lung fields and linear densities at the right lower base consistent with atelectasis.
Which of the following is the best next step in managing this patient?

Question

A 75-year-old man with moderate chronic obstructive lung disease is brought to the emergency department with acute onset of dyspnea that started this afternoon. He was discharged 2 days ago for a chronic obstructive pulmonary disease exacerbation treated with short-term noninvasive positive-pressure ventilation, corticosteroids, and antibiotics. He finished the oral antibiotics yesterday and has been nonambulatory since hospital discharge. He also complains of productive cough of whitish sputum and mild right-sided pleuritic chest pain. His other medical problems include hypertension, chronic lower-extremity edema with superficial ulcers, and severe right knee osteoarthritis.
His temperature is 37.2° C (99° F) , blood pressure is 120/73 mm Hg, pulse is 114/min, and respirations are 22/min. Pulse oximetry shows 89% on room air. Jugular venous pressure is estimated at 7 cm H₂O. Mild end-expiratory wheezing is heard bilaterally. There is bilateral, chronic-appearing edema of the lower extremities.
Laboratory results are as follows:

ECG shows sinus tachycardia with nonspecific T-wave changes. Chest x-ray shows hyperinflated lung fields and linear densities at the right lower base consistent with atelectasis.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

11ec193a_96a0_2dbe_853d_1d7812a73f49_MD0002_00 Chronic obstructive pulmonary disease (COPD) patients presenting with acute worsening dyspnea should be evaluated for potential causes such as pneumonia, heart failure, and pulmonary embolism (PE). This patient has 3 common symptoms of PE: pleuritic chest pain, dyspnea, and cough. In addition, he meets 3 of the modified Wells criteria (clinical signs of deep vein thrombosis, tachycardia, and immobilization), making PE likely with a total score of 6. Although D-dimer testing has a high sensitivity for PE, a negative D-dimer cannot be used to exclude PE in patients with high clinical probability. CT angiography is preferred in these patients to show the embolus as a filling defect or abrupt cutoff of a vessel. A high-probability V/Q scan can also diagnose patients with high clinical probability of PE if CT is unavailable. However, V/Q scan often provides false-positive results in those with underlying lung conditions and may need confirmatory CT (Choice E). (Choice B) Antibiotics and corticosteroids would treat COPD exacerbation. However, PE should be ruled out in this patient given the high pretest probability. (Choice C) Supplemental oxygen should first be given to correct this patient's hypoxemia prior to using noninvasive positive ventilation. (Choice D) Bedside transthoracic echocardiogram may show acute PE findings of increased right ventricular size, decreased right ventricular function, and tricuspid regurgitation. However, these findings are usually seen in massive PE (eg, hemodynamic instability). This patient's stable vital signs make this less likely. Educational objective: Unexplained or prolonged chronic obstructive pulmonary disease exacerbation may be due to pneumonia, heart failure, or pulmonary embolism (PE). A high index of clinical suspicion with modified Wells criteria can help in recognizing PE and determining its probability. CT pulmonary angiogram is the imaging modality of choice in those with a high clinical probability. __________ References: A postmortem analysis of major causes of early death in patients hospitalized with COPD exacerbation. (http://www.ncbi.nlm.nih.gov/pubmed/19318666) Update on acute pulmonary embolism. (http://www.ncbi.nlm.nih.gov/pubmed/20956134) Acute pulmonary embolism: the clinical conundrum (http://www.ncbi.nlm.nih.gov/pubmed/22340572)

A 75-Year-Old Man with Moderate Chronic Obstructive Lung Disease Is