in a severe inflammatory reaction causing pneumonitis. Early intubation is
critical.
Although you should always consider a foreign-body aspiration (b)in
the differential diagnosis of respiratory distress, it is not consistent with the
history of this individual. Reactive airway disease (a)typically presents
with wheezing and pneumothorax (e) with decreased breath sounds.
Decompression sickness (c)occurs when a scuba diver ascends too quickly
and dissolved nitrogen bubbles reenter tissues and blood vessels.
58.The answer is c.(Rosen, pp 1113-1114.)Pulmonary edemacan be
divided into cardiogenic and noncardiogenic. Cardiogenic varieties are
commonly seen in the ED and are usually a result of high hydrostatic pres-
sures. It is seen in patients with MI or ischemia, cardiomyopathies, valvular
heart disease, and hypertensive emergencies. Nitroglycerinacts to decrease
the preload of the heart by venous dilation. This lowers the work of the
heart so that it can function more effectively. A loop diureticis used to
induce diuresis and is also thought to act as a venous dilator. In conjunction
with one another, these medications act to improve the overall functional
capacity of the heart. If medical interventions are not stabilizing, prepara-
tion should be made for endotracheal intubation. Positive airway pressure
devices (eg, BiPAP) may also be used as a temporizing measure for oxygen
delivery.
(a)Morphine sulfate is a potent sedative and analgesic that also acts as
a venous dilator. Its effects on preload and afterload are relatively minimal
compared to nitroglycerin. It is also a respiratory depressant and should
only be given in small quantities for patients with pulmonary edema.
Aspirin (d) should be administered if there is suspicion of cardiac
ischemia. If this patient had pneumonia then antibiotics (e)should be
administered. However, the chest radiograph and clinical presentation is
consistent with acute pulmonary edema.
59.The answer is e.(Rosen, pp 986-998.) Legionella pneumophilais an
intracellular organism that lives in aquatic environments. The organism
may live in ordinary tap water and has probably been underdiagnosed in a
number of community outbreaks. It is typically seen in the elderly and
immunocompromised. Legionnaire disease is more common in the summer,
especially in August. Patients often experience a prodrome of 1 to 2 days of
mild headache and myalgias, followed by high fever, chills, and multiple
rigors. Cough is present in 90% of cases. Other pulmonary manifestations
68 Emergency Medicine