WBR0378

Author	PageAuthor::Mahmoud Sakr M.D.
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Allergy/Immunology, SubCategory::Respiratory
Prompt	[[Prompt::42 y/o female presents to the emergency room with rapidly progressive shortness of breath and wheezing. She’s cyanotic and disoriented. Her son is with her and provides you with some of her medical history. Her past medical history is significant for hypertension, diabetes and dyslipidemia. She was started yesterday by her primary care physician on a blood pressure medication, but her son cannot recall the name of the pill. Her vital signs are bp 123/92, RR 28, P 123, Temperature 37.2 C, O2 saturations are 82% despite high flow oxygen. On exam, she has stridor of the airway with gasping or wheezy inspiratory breath sounds. Which of the following is the most appropriate next step in management:]]
Answer A	AnswerA::IV antihistamine
Answer A Explanation	AnswerAExp::After the patient is intubated and her airway is secured, further management should be pursued such as antihistamines and IV steroids
Answer B	AnswerB::Call her primary care physician and ask about the name of the pill
Answer B Explanation	AnswerBExp::This is reasonable to do later when her PCP is available, however it is the not immediate step to be taken in such an emergency situation
Answer C	AnswerC::High dose IV steroids
Answer C Explanation	AnswerCExp::After the patient is intubated and her airway is secured, further management should be pursued such as antihistamines and IV steroids
Answer D	AnswerD::Endotracheal intubation
Answer D Explanation	AnswerDExp::Correct!
Answer E	AnswerE::IV normal saline
Answer E Explanation	AnswerEExp::The patient's blood pressure is stable at this time and does not need IV hydration.
Right Answer	RightAnswer::D
Explanation	[[Explanation::This patient is in severe respiratory distress with evidence of hypoxemia despite high flow oxygen, cyanosis and altered mentation. She most likely developed ACEI induced angioedema. The most important next step in management is intubation to save her life. You can then proceed with IV steroids and antihistamines. It’s also reasonable to call her primary care physician as soon as possible to confirm the diagnosis. IV normal saline will be of little use in treating this condition unless she develops hypotension. Educational Objective: References: ]]
Approved	Approved::Yes
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