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Old 08-31-2012
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Question Most appropriate next step

55 year old man arrive at emergency department with fever shortness of breath. He has smoke two packs of cigarettes per day for at least 30 year. Temp 38.5 C, RR 26/min, pulse of 110/min, BP 125/65. The physical examination is significant for decrease breath sound, with crackles at the base bilaterally. ABG shows hypoxia. CXR shows bilateral lower lung field infiltration.
CBC:*WBC: 4,500/mm *Neut: 94% *lymph:2% *Mono:2% *Eosin:1%
What is the most appropriate next step?
A- Bronchoscope with Bronochoalveolar lavage
B- Immunofluorescence of induce sputum sample
C- Pulmonary function test
D- Treated with Ceftriaxone and Azithromycin
E- Admit the patient and treated with Albuterol, Inhaled steroid and Cefuroxime
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Old 08-31-2012
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I will go with Answer D
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Dint look at "ABG shows hypoxia "

I will go with Answer E .
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answer seems to be E......exacerbation of COPD
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Matched!!!
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Old 08-31-2012
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Would go with E, hypoxia is an indication for admission & his smoking hx gives clue to COPD exacerbation
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Old 08-31-2012
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Although E looks correct ....... but was wondering if we should do PFT first , he might need intubation if severe decrease in FEV1 ............
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Quote:
Originally Posted by step_enhancer View Post
Dint look at "ABG shows hypoxia "

I will go with Answer E .
pH 7.4
PCO2 32mm Hg
PO2 54mm Hg
HCO3 20mEq/l

Quote:
Originally Posted by heartbeat View Post

55 year old man arrive at emergency department with fever and shortness of breath. He has smoke two packs of cigarettes per day for at least 30 year. Temp 38.5 C, RR 26/min, pulse of 110/min, BP 125/65. The physical examination is significant for decrease breath sound, with crackles at the base bilaterally. ABG shows hypoxia. CXR shows bilateral lower lung field infiltration.
Can the diagnosis be pneumonia?
If yes, what is the most likely organism?
Then try to confirm the diagnosis first or rush to treat the patient?

Last edited by heartbeat; 08-31-2012 at 11:31 AM.
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Old 08-31-2012
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He has two things going on together ,He has COPD exacerbation(Shortness of breath,smoker and Hypoxia) and pneumonia (fever and bilateral lower lung infiltrates)
In this case we have to rush to the treatment because of hypoxia ,we need to admit her and start empirical antibiotics and bronchodilators.
So treatment is choice E
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Old 08-31-2012
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"If yes, what is the most likely organism?"

In this question u dont have to worry about it coz u dont have to choose one antibiotics from many .just a broad spectrum antibiotic will do
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Old 08-31-2012
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Any other suggestions
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Quote:
Originally Posted by heartbeat View Post
Any other suggestions

A- Bronchoscope with Bronochoalveolar lavage seems like a very good answer choice and would be my answer to find out the cause of atypical pneumonia since he is hemodynamically stable despite hypoxia on ABG

WBC: 4,500/mm doesn't add up towards a garden variety pneumonia.
But he has hypoxia with bilateral crackles and infiltrates pointing towards atypical pneumonia. So, D- Ceftriaxone and Azithromycin is a good option


E cannot be the right answer since he does not have wheeze so albuterol and steroids are not going to help.
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Old 08-31-2012
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If he has community acquired pneumonia and you are thinking atypical pneumonia variety....what is the role of ceftriaxone which works on bacteria capsule...and remember most atypical organisms lack that capsule...

I would go for A....
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Old 09-01-2012
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Correct Answer

Novobiocin U R right most probably diagnosis from the presentation is sever Atypical pneumonia .
But the tricky in this question is low lymphocyte count(2% of 4500= 90 lymphocyte/mm, thus CD4 must be even lower) and this suggestive of immunocompromised status. HIV and PCP are very likely possibility in this patient.So before we rush to treat the patient, we should confirm the diagnosis of PCP by Immunofluorescence of an induce sputum sample. If the test is +ve no need to do further testing. if the test is -ve in patient for whom there is high clinical suspicious of PCP Bronchoscopy with bronchoalveolar lavage is best diagnostic test.

Again Novobiocin U R right since the patient does not have wheeze albuterol and steroids are not going to help.

stfidel you are right Atypical pneumonia not treated with ceftriaxone

Last edited by heartbeat; 09-01-2012 at 02:08 AM.
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