A 75-year-old male with a history of tobacco use (50 pack year), chronic obstructive pulmonary disease (COPD), hypertension (HTN), and recent diagnosis of adenocarcinoma of the lung for which he has not started treatment presents to the ED with a 4-day history of increased dyspnea at rest and with exertion, productive cough, and subjective fevers at home. His initial vitals were notable for:
He was placed initially on a nonrebreather and his saturations increased to 92%. He had a CXR performed which showed a dense consolidation in the right lower lobe. He was started on ceftriaxone and azithromycin for community-acquired pneumonia (CAP) and admitted to the ICU given his high oxygen requirements. Three days into his ICU course, his high flow requirements remained unchanged. He remained tachycardic in the low 100s and continued to have low-grade fevers.
What would be the next step in management?A. Add vancomycin for greater antibiotic coverage
Correct Answer: C
The patient continues to demonstrate tachycardia, hypoxemia, and lowgrade fevers. However, he also displays clinical and subjective findings to suggest improvement in his pneumonia with reduced cough and rhonchi. Given the patient has an underlying diagnosis of non–small-cell lung cancer, he is at increased risk for the development of PE. In comparison to cancer-free controls, patients with lung cancer were six times more likely to develop a PE. He also has a recent diagnosis of malignancy, and the incidence of PE is greatest within the first 6 months of lung cancer diagnosis. The patient has been diagnosed with adenocarcinoma which independently is a risk factor for PE (OR 3.6). Given is lack of improvement and his associated risk factors, a CT-PE would be warranted to rule out a PE as the cause for his continual symptoms. Adding on vancomycin would not be appropriate, given the patient has low methicillin-resistant Staphylococcus aureus (MRSA) risk factors. Steroids would likely not be helpful as clinically the patient does not appear to have a COPD exacerbation and his sputum production is improving and he has no evidence of wheeze on examination. In patients, without significant risk factors for PE, it may be appropriate to wait for clinical improvement, given the patient did have an initial diagnosis of pneumonia, however, missing a PE in this patient could be life threatening.