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

question 166

Multiple Choice

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?

• A)Computed tomography angiography of the chest
• B)Intravenous antibiotics and corticosteroids
• C)Noninvasive positive ventilation
• D)Transthoracic echocardiogram
• E)V/Q scan

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Definitions:

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