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You are called to the emergency department to see a patient who is complaining of SOB. An order has been written for bronchodilator treatment. On arrival, you find a 65-year-old moderately obese man sitting upright on the examination table in a single-patient examination room. You observe that his respiratory rate is about 20 breaths/minute, with pursed-lip breathing and slight cyanosis around the lips, and he is unable to say more than a few words per breath. He is complaining of right elbow pain. His heart rate is 126 beat/minute and irregular. On auscultation, you hear fine crackles in both lung bases. He reports a nonproductive cough for the last 2 days, with increasing SOB, an inability to lie flat, and increasing leg pain. You notice that he is unable to tie his shoes because his feet are swollen and that his legs are very red, shiny, and painful to the touch. His current PEF is 50% of predicted. A room air ABG was done before your arrival: pH, 7.47; Paco2, 32 mm Hg; Pao2, 53 mm Hg; HCO3 −, 23 mEq; BE, 0; Sao2, 89%. No chest radiograph has been ordered yet.
You give the ordered bronchodilator treatment with O2, but the patient reports no subjective relief. No changes in vital signs are noted. His color does improve a little during the treatment (O2 at 6 L/minute via smallvolume nebulizer), and his breath sounds are unchanged. His cough is nonproductive, and there is no measurable change in the peak flow after treatment.