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A 64-year-old man presents to the physican's office complaining of fevers for the past 2 days. Over the past 24 hours, he has developed a productive cough. He also reports that he has frequent chills, and has been waking for the past 2 nights with drenching sweats. His past medical history is remarkable only for mild exertional angina. On physical examination, he does not appear chronically ill but appears moderately dyspneic. His temperature is 38.6 C (101.4 F), blood pressure is 136/94 mm Hg, and respirations are 26/min. There is no jugular venous distention. The lungs have coarse rhonchi at the right lung base with increased fremitus in the same area. He has a regular heart rhythm, with a 1/6 systolic murmur at the left sternal border. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in diagnosis?
A. Chest x-ray film
B. Sputum Gram's stain
C. Chest CT scan
D. Pulmonary function test
E. Peak expiratory flow rate measurement
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The correct answer is
B. This patient has a classic presentation of an acute community acquired bacterial pneumonia, as demonstrated by the findings of acute onset of fevers, rigors, and a productive sputum. His physical examination is consistent with a right lower lobe pneumonia and consolidation in this region. A sputum Gram's stain may demonstrate the organism responsible for this patient's pneumonia. The next step would then be a chest x-ray to confirm the presence of a pneumonia and identify its size and any associated parapneumonic effusions.
A chest x-ray film (choice A) is also indicated, but may take an hour or more to actually be obtained. For this reason, collecting sputum for a Gram's stain, before the x-ray, may shorten the time to definitive therapy.
Chest CT scan (choice C) is usually reserved for evaluation of suspected masses.
Pulmonary function tests (choice D) and peak expiratory flow rate measurement (choice E) are usually reserved for evaluation of chronic lung diseases, such as emphysema, chronic bronchitis, pulmonary fibrosis, and asthma.
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sounds like a typical pneumonia, agree with Zkadhem, A sounds right.
Hope there is no trick here...
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LOLLLLL this is very fishy question not just tricky
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sputum culture takes days and sometimes even weeks. I do not see the reasons why we need to rush for an extra hour here. chest x-ray should be the no1 and then followed by empirical antibiotics based on s/s. we could not wait for culture results bf starting the rx.
not convinced.
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this is why i say it is fishy and tricky...at the end we will never wait for the sputum to start treatment
