A 72-Year-Old Man Comes to the Emergency Department Due to Progressive

question 977

Multiple Choice

A 72-year-old man comes to the emergency department due to progressive shortness of breath and cough productive of yellowish sputum.  The patient says, "I have been feeling breathless for the past several months while mowing the lawn or walking around the house, but it has been worse over the last 3 days."  He has had no chest pain or leg swelling but notes that his heart "has been racing."  The patient has a history of hypertension, peptic ulcer disease, and osteoarthritis.  He was hospitalized for pneumonia a year ago and required intravenous antibiotics.  Six months ago, the patient underwent a cardiac stress test for chest discomfort, which was unremarkable.  The patient has smoked a pack of cigarettes daily for 45 years.  Blood pressure is 160/90 mm Hg, pulse is 148/min, and respirations are 26/min.  He is speaking in partial sentences and using accessory muscles of respiration but is alert and cooperative.  There is no jugular venous distension or heart murmurs, rub, or gallops, but the heart sounds are irregular.  Lung auscultation reveals bilateral rhonchi and expiratory wheezes.  Arterial blood gases while breathing 2 L of oxygen via nasal cannula reveal PO₂ of 66 mm Hg, PCO₂ of 52 mm Hg, and pH 7.33.  ECG shows narrow QRS complexes with distinct P waves of different morphologies and variable PR segments and R-R intervals.  Chest x-ray reveals no pulmonary infiltrates or consolidation.  Inhaled bronchodilators and systemic glucocorticoids are administered.
Which of the following is the most appropriate additional step in management of this patient's arrhythmia?

• A)Intravenous amiodarone
• B)Intravenous diltiazem
• C)Intravenous esmolol
• D)Noninvasive ventilation
• E)Synchronized cardioversion

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Definitions:

Refreezing Phase

The final step in the Lewin's change model where new behaviors or changes are solidified into the organization's culture, making them standard practice.

Performance-Contingent Rewards

Rewards or incentives that are given to employees based specifically on their performance or achievements.

Positive Reinforcement

Strengthens a behaviour by making a desirable consequence contingent on its occurrence.

Force-Coercion

A change strategy that involves using power to induce change through pressure or the use of authority, often leading to compliance but not necessarily agreement.