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23 YO male is history of asthma, presented to the ER with SOB & wheezing, at ER they started O2 supplementation.

What is the best step to do in this patient to take him out of this exacerbation state? 1. 2. 3. 4. 5. Albuterol Anticholinergic drug Steroid Albuterol & antibiotics Pulmonary function tests

(The answer is 3. Steroid.

The best step to do to take the patient out of the state of acute attack is Steroid. The best step to improve the hypoxemia after O2 is bronchodilater. As you know guys, asthma is inflammatory state, beside hyperreactive bronchi. To take the patient out of the inflammatory state is steroid.)

Question 1
A 31-year-old obese female with a history of asthma comes to your office complaining of severe shortness of breath and wheezing. She produces from her purse a number of active medications including a beclomethasone metered dose inhaler (MDI) and salmeterol MDI. She also appears to be taking zafirlukast daily. She tells you that she has been hospitalized many times for asthma flares and was once intubated. Her review of systems is pertinent for asthma attacks of increasing severity over the past few weeks but she denies any fever, cough, chills, or pleuritic chest pain. On exam, the patient demonstrates audible expiratory wheezes with a markedly prolonged expiratory time. Her respiratory rate is 20-24/min and she is acutely short of breath, using accessory muscles of respiration to breathe. Her vital signs are otherwise stable. Which of the following is the most beneficial management of this patient? (A) Obtain a chest radiograph to rule out pneumonia (B) Obtain a peak flow estimate (C) Albuterol nebulizer therapy in the office (D) Refer the patient to the local hospital for admission (E) Refer the patient to the local emergency room for evaluation and treatment

The correct answer is E. A patient with severe asthma who has had multiple previous admissions for asthma must be treated emergently. Although she presented in an office setting, simply managing her current flare in an outpatient setting is not sufficient, as these patients tend to decompensate rapidly. She is already in mild-tomoderate respiratory distress and will only get worse if appropriate therapy is not initiated. If she worsens, the office setting is no place to manage her. Getting a chest radiograph to rule out pneumonia (choice A) would be acceptable if this patient's condition were not acute. Since the overriding concern is for impending respiratory collapse, she should be triaged to a local ER and have a chest radiograph taken under more controlled conditions. Documenting a peak flow estimate (choice B) is not going to alter any management decisions. Even if her flows were not markedly depressed, she is still in moderate respiratory distress and is not moving air well. Initiating albuterol nebulizer therapy (choice C) may be beneficial, and if the therapy is successful, the acuity of the situation has passed. However, if the therapy fails to be effective, then valuable time has been lost and the patient's condition will likely be more critical.

Referring the patient to the local hospital for admission (choice D) is not equivalent to having her seen and evaluated in the emergency room. Given that this patient is in near extremus, she requires evaluation and therapy by the ER team.