Patient Case Questions: Pulmonary

DL is a 26yo male (62kg) with a history of uncontrolled asthma requiring intubation. He is currently on fluticasone propionate and salmeterol 500mcg/50mcg bid, montelukast 10mg po qhs, and albuterol prn, which he uses on “most days.” He is brought into the ED having what appears to be an asthma exacerbation. Vital signs are as follows: temperature 99.1°F, HR 82, RR 28, BP 92/68, O₂ saturation 96% on RA. He is audibly wheezing and resting his hand on his legs while he breathes, but otherwise is well-appearing.

A1) The physician immediately orders nebulized ipratropium and high-dose albuterol, which DL tolerates well, and a dose of IV methylprednisolone. Which of the following agents is most reasonable to recommend as adjunctive therapy at this time?

DL is a 26yo male (62kg) with a history of uncontrolled asthma requiring intubation. He is currently on fluticasone propionate and salmeterol 500mcg/50mcg bid, montelukast 10mg po qhs, and albuterol prn, which he uses on “most days.” He is brought into the ED having what appears to be an asthma exacerbation. Vital signs are as follows: temperature 99.1°F, HR 82, RR 28, BP 92/68, O₂ saturation 96% on RA. He is audibly wheezing and resting his hand on his legs while he breathes, but otherwise is well-appearing.

A2) Though DL was initially stable appearing, his respiratory rate is increasing, and he appears to be tiring out from the increased work of breathing. After a failed trial of BiPAP DL is starting to desaturate and the physician determines intubation is necessary. Which of the following is the most appropriate induction agent to recommend?

PZ is a 62yo female who recently flew from her home in New York to spend the winter in Florida. She presents to the ED with cough and shortness of breath. She has no chronic conditions and the only medication that she takes is azithromycin, which was called in by her primary care physician three days ago for pneumonia. She was sent in by her primary care provider for admission and IV antibiotics since she failed outpatient treatment. Her temperature is 100.8°F, RR 19, HR 89, BP 122/72, O₂ saturation 98% on room air. She has a productive cough, and a chest x-ray is consistent with pneumonia. Labs are unremarkable except for a WBC of 11.3.

P1) Which of the following is the most appropriate recommendation for antibiotic therapy in PZ?

LR is a 78yo male who presents to the ED with a 5-day history of cough, shortness of breath, and subjective fevers. He has a past medical history significant for hypertension, hyperlipidemia, diabetes, atrial fibrillation, CHF, and CKD, and an admission last month for a UTI where he received ceftriaxone. Allergies include penicillin (rash) and sulfa (hives). Upon presentation his vital signs are as follows: temperature 100.7°F, BP 155/88, HR 82, RR 22, O₂ saturation 96% on RA. His labs are unremarkable except a SCr of 1.4 (appears to be at his baseline) and a WBC of 12.2.

P2) Which of the following is the most appropriate empiric antibiotic regimen for LR?

TM is a 68yo female who presents to your ED with shortness of breath. She thinks that this is an exacerbation of her COPD as she has been coughing up more sputum. At home is on a fluticasone furoate, umeclidinium & vilanterol combination inhaler but denies using oxygen. She has reported allergies to penicillin and doxycycline, both of which cause hives. She is visibly struggling to breathe and her initial O₂ saturation is 83%. The decision is made to start her on BiPAP

C1) While on BiPAP, TM is becoming increasingly agitated and trying to rip the mask off stating that she “can’t breathe.” Which of the following is the most appropriate sedative to facilitate BiPAP tolerance in TM?

TM is a 68yo female who presents to your ED with shortness of breath. She thinks that this is an exacerbation of her COPD as she has been coughing up more sputum. At home is on a fluticasone furoate, umeclidinium & vilanterol combination inhaler but denies using oxygen. She has reported allergies to penicillin and doxycycline, both of which cause hives. She is visibly struggling to breathe and her initial O₂ saturation is 83%. The decision is made to start her on BiPAP

C2) TM’s primary care physician comes through to admit her and would like to start her on antibiotics as she has increased dyspnea and sputum volume and requires mechanical ventilation. He is concerned because her QTc is prolonged at 454 msec. Which of the following is the most appropriate agent to recommend?

JR is a 52yo male brought into the ED for facial swelling and angioedema. He has no known allergies, and his past medical history is significant for hypertension for which he takes lisinopril. Vital signs are stable, and the patient does not appear to be in distress.

AR1) The physician orders IV tranexamic acid for JR. Which is the following is the rationale for administering tranexamic acid in JR?

SM is the mother of LT, an 8yo boy that came into your ED earlier this week with an allergic reaction. She calls frantically because the pharmacy misfiled his Epi-Pen, giving him an adult Epi-Pen instead of the Epi-Pen Jr that he usually gets. Upon reviewing his chart, you see that he was prescribed the full-dose Epi-Pen rather than the Epi-Pen Jr, and you note that his weight was charted as 32kg.

AN1) Which of the following is the most appropriate response for SM regarding LT’s Epi-Pen

TA is a 34yo female who presents to your ED with itching and shortness of breath after a potluck at work. She has a known anaphylactic allergy to shellfish but was told that all the dishes brought in were safe for her to eat. She used her Epi-Pen before EMS arrived, but she is concerned that it is wearing off and that her airway is “closing up” again. Her vital signs are as follows: temp 98.6°F, HR 110, RR 22, BP 88/56, O₂ saturation 97% on RA. She is audibly wheezing, which can be heard across the room. 

AN1) Which of the following agents is the most important for TA and should be administered first?

TA is a 34yo female who presents to your ED with itching and shortness of breath after a potluck at work. She has a known anaphylactic allergy to shellfish but was told that all the dishes brought in were safe for her to eat. She used her Epi-Pen before EMS arrived, but she is concerned that it is wearing off and that her airway is “closing up” again. Her vital signs are as follows: temp 98.6°F, HR 110, RR 22, BP 88/56, O₂ saturation 97% on RA. She is audibly wheezing, which can be heard across the room. 

AN2) After administration of epinephrine, diphenhydramine, methylprednisolone, and famotidine as well as albuterol and IV fluids, TA is feeling much better and would like to go home. Which of the following factors is most important to consider regarding TA’s discharge disposition?