From the Guidelines
The patient should be managed conservatively with close monitoring for 24 hours, given the negative CT scan and absence of significant complications, while also addressing their underlying COPD and other chronic conditions. The patient's presentation suggests a mild head injury without significant complications, and the negative CT scan, absence of fractures, pneumothorax, or pleural effusion support this approach 1. The elevated WBC count (11.3) may be related to stress response or underlying COPD rather than infection, as noted in the 2018 GOLD report, which emphasizes that COPD is a treatable condition and that most patients have mild disease that requires little other than smoking cessation, immunizations, and as-needed short-acting bronchodilator therapy 1. Key considerations in the patient's management include:
- Monitoring for neurological changes every 2-4 hours for 24 hours
- Pain management with acetaminophen 650mg every 6 hours as needed, avoiding NSAIDs due to fall risk
- Management of COPD with regular medications, ensuring proper inhaler technique and adequate hydration, as recommended by the Global Initiative for Chronic Obstructive Lung Disease report 1
- Follow-up imaging for lung nodules in 3-6 months if not previously scheduled
- Cardiology follow-up within 2-4 weeks for the moderate cardiomegaly and tortuous aorta
- Implementation of fall prevention strategies, including physical therapy evaluation, home safety assessment, and review of medications that might contribute to fall risk. It is also important to note that COPD is commonly both overdiagnosed and underdiagnosed, and associated comorbidities, such as heart disease, are particularly important, as most patients die either of lung cancer or of heart disease, rather than COPD itself 1.
From the Research
Patient Profile
- 73 years old
- Recent fall with head injury, but CT scan is negative
- COPD patient with nodules in lungs
- Elevated WBC count (11.3)
- Chest X-ray shows limited inspiration, no displaced fracture, no pneumothorax or pleural fluid, and a moderately enlarged heart with a tortuous thoracic aorta
Management of COPD
- The goal of COPD management is to delay disease progression and alleviate symptoms 2
- Monitoring of lung function indices, symptoms, exercise tolerance, comorbidity, and smoking habits are recommended regularly 2
- Pharmacotherapy and smoking cessation are the mainstays of treatment, with pulmonary rehabilitation, long-term oxygen therapy, and surgery considered in select patients 3
Antibiotic Therapy for COPD
- Azithromycin may reduce treatment failure in patients with acute COPD exacerbations requiring hospitalization 4
- Prophylactic antibiotic therapy may reduce exacerbations in COPD patients, but there is concern about antibiotic resistance and safety 5
- Different classes of antibiotics (e.g. macrolides, tetracyclines, quinolones) may have varying efficacy and safety profiles for COPD prophylaxis 5