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Old 07-23-2013
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Help Treatment for Acute Streptococcal pneumonia in healthy young male

A 26-year-old man who was previously healthy has a acute onset (over 10 hours) of severe sharp, stabbing, chest pain and a temperature of 102  F when he consults you in the evening. He does not smoke, and has no allergies. Physical examination reveals a temperature of 102 F, a pulse of 110, and a blood pressure of 124/82. He appears to be in great distress, being both toxic and in much pain with inspiration. Chest examination reveals bronchophony, egophony, and dullness to percussion in the right posterior chest. There are some “sticky” rales in this area, too. Chest x-ray reveals a right lower lobe infiltrate. A sputum Gram stain reveals gram-positive diplococci.
Tx?

A) Penicillin
B) Trimethoprim/sulfamethoxazole
C) Postural drainage
D) Tetracycline
E) Cefadroxil

Please share your answers.

Would your answer differ if there were F) Azithtromycin?
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Old 07-23-2013
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Default

Quote:
Originally Posted by smartmark View Post
A 26-year-old man who was previously healthy has a acute onset (over 10 hours) of severe sharp, stabbing, chest pain and a temperature of 102  F when he consults you in the evening. He does not smoke, and has no allergies. Physical examination reveals a temperature of 102 F, a pulse of 110, and a blood pressure of 124/82. He appears to be in great distress, being both toxic and in much pain with inspiration. Chest examination reveals bronchophony, egophony, and dullness to percussion in the right posterior chest. There are some “sticky” rales in this area, too. Chest x-ray reveals a right lower lobe infiltrate. A sputum Gram stain reveals gram-positive diplococci.
Tx?

A) Penicillin
B) Trimethoprim/sulfamethoxazole
C) Postural drainage
D) Tetracycline
E) Cefadroxil

Please share your answers.

Would your answer differ if there were F) Azithtromycin?
Cephadroxil. Yes would pick Azithromycin if it was an option
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  #3  
Old 07-24-2013
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Default Answer

Thx GamX. I was thinking the same.

However, the "correct" answer was supposed to be A).
Quote:
Originally Posted by NMSfamilymedQA
Penicillin remains the drug of choice in this typical community-acquired case in a previously healthy person with lobar pneumonia. The etiologic agent maybe assumed to be caused by S . pneumoniae . Because of the acuteness of the case, this patient will need to be hospitalized for a day or two but should respond dramatically.
...
If the patient is allergic to penicillin, then most clinicians would employ a macrolide antibiotic, such as clarithromycin.
Cefadroxil is classified as a first-generation cephalosporin but is generally more effective against the gram-negative spectrum and usually considered in “below the waist” infections.
But I am not satisfied with this explanation: S. pneumoniae frequenty has penicilinase, right? So simple penicillin should not be right.

My approach is
For CAP:
- young (should cover atypical Mycoplasma...): Azithromycin
- old (typical pneumonia more likely):
-if without comorbidities: 2nd or 3rd Cephalosporin
-if with comorbidities or antibiotics in the last 3months: fluoroquinolone.

Applied for this case: he is young, but presents as typical Streptococcal pleumonia (mycoplasma excluded), without comorbidities, so 2nd or 3rd Cephalosporin is OK.

What do you think?
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