Kaplan USMLE Step 2: 70-year-old woman in respiratory distress

If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.

A 70-year-old woman is brought to the emergency department because of a two-day history of productive cough with yellow-green sputum and shortness of breath. She has a history of hypertension, coronary artery disease, osteoarthritis and gastroesophageal reflux disease. She has no recent hospitalizations. She lives with her husband and performs most activities of daily living by herself. Current medications include nitroglycerin, aspirin, atenolol and omeprazole. Her temperature is 39.8ºC (103.6ºF), pulse is 120/min, respirations are 32/min, blood pressure is 128/66 mm Hg and oxygen saturation is 94% on oxygen 2 L/min via nasal cannula. Physical examination shows a patient in respiratory distress. There are decreased breath sounds and crackles bilaterally. Laboratory studies show a leukocyte count of 14,100/mm³. A chest radiograph is shown. Which of the following is the most appropriate pharmacotherapy for this patient?

Chest radiograph goes here - this image is missing from the Googledoc.

A. Aspirin

B. Azithromycin and ceftriaxone

C. Cefepime and ciprofloxacin

D. Cefepime and vancomycin

E. Furosemide

The correct answer is B.

This is a patient with community-acquired pneumonia that requires inpatient treatment based on her age (>65 years) and respiratory rate (>30/min). The most appropriate pharmacotherapy is an antipneumococcal beta-lactam plus a macrolide, an example being ceftriaxone and azithromycin.

Choice A. This patient has an infectious process that requires antibiotic treatment. As such, non-antibiotic pharmacotherapy options choices can be eliminated.