Question of the Week # 105

105) A 66 year old man presents to your office with complaints of productive cough and low grade fever for past two days. He denies any sick contacts. On physical examination, his temperature is 100F, breath sounds are reduced in left lower lobe. A chest x-ray reveals left lower lobe infiltrate. Laboratory investigations reveal WBC count of 12,ooo/µl with 80% neutrophils. Sputum gram stain and cultures are sent for. Blood cultures have been obtained and are pending.  He received a Flu vaccine about one month ago but never received a pneumococcal vaccine. The next important step in managing this patient:

A) Oral Azithromycin

B) Oral Levofloxacin

C) Admit the patient

D) Swallowing evaluation

E) PPD skin test


12 Responses

  1. A


  2. a

  3. A but I’m not certain..Exposure to influenza virus can cause pneumonia with fevers for 3-8 days with prostration, but this looks like community acquired pneumonia. begins outside hospital or within 48 hrs of admissinon if not longterm care facility patient. Pneumonia pts typically admitted if severe systemic conditions – like PORT risks CMDT2007, p. 254 – CHF, liver or renal diseases, this patient is 66 and not too severe so have as outpt. No electrolytes or vitals. Old recs were use macrolides firstline and keep fluroquinolones as alternatives…but this may be changing due to resistance….any critical care or ID feedback? I’m a generalist IMG intending to help.

  4. Answer: C , CURB65/ pt. needs to be admitted

    • patient with curb65 with 1 criteria can be treated as op

      • Hi DR Raj, I think we don’t know enough about this patient. Here we can not apply CURB65 or PSI (Pneumonia Severity Index). What is the most important next step if we can’t apply CURB65 or PSI? -That’s the core to the answer. My Answer; C, Admit in ER for 24 hours at least; then if I feel he can be managed as outpatient, he can be discharged. Please note that with the information provided in this question, it is difficult to rule out severe pneumonia. However, after 12- 24 hours admission in ER, you will have a profile of the vitals, lab results, and one will be more confident to say if this patient is getting better or worse and whether he is fit for home and outpatient management. It doesn’t make sense but it is better to be safe than sorry. Think again, if you don’t know the baseline of this patient, you can not send him home or manage him as outpatient. There is a chance that this patient may need ICU admission, now or the next time he presents so I think we should be careful. We should admit him now.

  5. The score is an acronym for each of the risk factors measured. Each risk factor scores one point, for a maximum score of 5:
    Confusion of new onset (defined as an AMT of 8 or less)
    Urea greater than 7 mmol/l (19 mg/dL)
    Respiratory rate of 30 breaths per minute or greater
    Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less
    age 65 or older

    Patients with any type of infection (half of the patients had pneumonia), the risk of death increases as the score increases[2]:
    0 to 1 <5% mortality
    2 to 3 < 10% mortality
    4 to 5 15-30% mortality

  6. We can’t apply CURB65 or PSI (Pneumonia Severity Index) here. There is insufficient information.
    What is the most important next step in the management of this patient? Assess the severity of the pneumonia.
    Right now, we can’t do that.
    In this scenario, we don’t know anything about his vitals and labs. We should admit him until we have comfortably assessed the severity of his pneumonia.
    My answer is C -Admit him (until we have a fair assessment)
    If the RR turns out to be 35, Oxygen saturation 68, Diastolic 50 mmHg, in the next hour and the BUN rises over the next 6 hours, we would consider our decision as the best decision in retrospect. A good clinician on thoroughly and he/she would not allow his patients to get worse at home or present with complications from home.
    We can’t let this patient go home until we have assessed him properly and until we are sure he is stable and he can endure home and outpatient management.
    Thank you.

    • Line eleven, something was omitted, sorry about that. The sentence is; ‘A good clinician assesses his patients thoroughly…and he/she would not allow his patients to get worse at home or present with complications from home.’

    • dude– The symptoms of pneumococcal pneumonia usually go away within 12 to 36 hours after you start taking medicine.– in real life Pt start to get better even sooner — this Pt has no indication of hospitalization with 12 WBC and mild fever of 2 days —

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