#april2020mccqe1
A 64-year-old man with a history of chronic obstructive pulmonary disease is evaluated in the emergency department for increased dyspnea over the past 48 hours. There is no change in his baseline production of white sputum, but he has increased nasal congestion and sore throat. His medications are inhaled tiotropium, fluticasone, salmeterol, and albuterol. Therapy with methylprednisolone, inhaled albuterol, and ipratropium bromide is started.
The patient is alert but in mild respiratory distress. The temperature is 38.6°C (101.5°F), the blood pressure is 150/90 mm Hg, the pulse rate is 108/min, and the respiration rate is 30/min. Breath sounds are diffusely decreased with bilateral expiratory wheezes; he is using accessory muscles to breathe. With the patient breathing oxygen, 2 L/min by nasal cannula, arterial blood gases are pH 7.27, PCO2 60 mm Hg (8.0 kPa), and PO2 62 mm Hg (8.2 kPa); oxygen saturation is 91%. Which of the following is the most appropriate next step?
(A) Increase oxygen to 5 L/min
(B) Intubation and mechanical ventilation
(C) Start aminophylline infusion
(D) Start noninvasive positive-pressure ventilation
A 64-year-old man with a history of chronic obstructive pulmonary disease is evaluated in the emergency department for increased dyspnea over the past 48 hours. There is no change in his baseline production of white sputum, but he has increased nasal congestion and sore throat. His medications are inhaled tiotropium, fluticasone, salmeterol, and albuterol. Therapy with methylprednisolone, inhaled albuterol, and ipratropium bromide is started.
The patient is alert but in mild respiratory distress. The temperature is 38.6°C (101.5°F), the blood pressure is 150/90 mm Hg, the pulse rate is 108/min, and the respiration rate is 30/min. Breath sounds are diffusely decreased with bilateral expiratory wheezes; he is using accessory muscles to breathe. With the patient breathing oxygen, 2 L/min by nasal cannula, arterial blood gases are pH 7.27, PCO2 60 mm Hg (8.0 kPa), and PO2 62 mm Hg (8.2 kPa); oxygen saturation is 91%. Which of the following is the most appropriate next step?
(A) Increase oxygen to 5 L/min
(B) Intubation and mechanical ventilation
(C) Start aminophylline infusion
(D) Start noninvasive positive-pressure ventilation
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