acutely identifying the organism in community-acquired pneumonia and
silver stain is required to see pneumocystis. Nebulizer treatment (d)is
ancillary and may provide relief of symptoms in a wheezing patient with
pneumonia, but is not appropriate for initial management of this patient.
Epinephrine(e)has no role in the acutely ill patient with PCP whose symp-
toms are less likely related to severe reactive airway disease.
73.The answer is a.(Rosen, pp 938-956.)This patient is suffering from
anexercise-induced asthma exacerbation.Various triggers can cause
bronchospasm. These include dust, various perfumes, underlying upper-
respiratory infections, cigarette smoke, menstrual flow, and various medica-
tions including aspirin. The medical intervention in this patient should
include a β 2 -agonist nebulized solution, corticosteroids, and oxygen admin-
istration. The most useful measure to track the patient’s progress with each
treatment is a peak expiratory flow,and should be a part of the initial
assessment and monitoring. The forced expiratory volume in 1 second from
a maximal inspiration (FEV 1 ) may be used in the ED setting. More com-
monly, peak flow meters are used which measure the peak expiratory flow
rate in liters per second starting with fully inflated lungs. Both of these mea-
surements require full patient cooperation whose values should be the aver-
age of three consecutive forced expirations. Normalized value ranges are
determined by the patient’s age, sex, and height.
A chest radiograph (b)is useful if the patient does not improve after
standard asthma treatments and there is suspicion of a different etiology for
the patient’s dyspnea. Brain-natriuretic peptide (c)is a natural enzyme pro-
duced by the atria of the heart and is elevated when there is stretching of
these fibers, as occurs in CHF. The peptide then acts as a natural diuretic
and vasodilatory agent in lowering stress on the heart. This value is not ele-
vated in asthma. A rectal temperature (d)is not a necessary next step, but
may be utilized at a later time when evaluating infection as another trigger.
An ABG (e)is a useful assessment of oxygenation and the degree of airway
obstruction initially. However, it is important to note that pretreatment and
posttreatment ABGs do not correlate well with the patient’s clinical picture
and may take longer to normalize.
76 Emergency Medicine