08-10-2009, 01:54 PM
A 74-year-old woman is sent to the emergency department
after being found in a confused state at her longterm
care facility. For the past 2 weeks she has been acting
œnot quite herself. According to nursing staff at the
facility, she has had a cough that seems worse during
meals, and occasional low-grade fevers, though no rigors.
Before this episode the patient had been fairly functional
but required physical therapy and nursing for a
recent stroke and resulting left-sided hemiparesis. Vital
signs on time of arrival are temperature of 38.0 C
(100.4 F), blood pressure of 108/68 mm Hg, pulse of
108/min, and respirations of 24/min.An oxygen saturation
obtained with the patient™s vital signs is 85%. The
woman is confused and oriented only to self. She has a
cough and produces some foul-smelling green sputum.
Physical examination is remarkable for inspiratory
crackles heard over the right mid lung zone and right
lung base. Tactile fremitus is increased in this area and
bronchial breath sounds are also present. Laboratory
studies show:
Hematologic
Leukocyte count 20,000/mm3
Neutrophils, segmented 70%
Neutrophils, band 18%
Hematocrit 35%
Platelet count 368,000/mm3
A urinalysis and routine set of chemistries are unremarkable.
A chest radiograph reveals a patchy,
ill-defined opacity in the superior segment of the right
lower lobe, with a small area of central cavitation. Given
this patient™s presentation, the most appropriate treatment
is to
(A) begin trimethoprim/sulfamethoxazole and prednisone
(B) obtain high-resolution CT scan of the lung
© order bronchoscopy with biopsy
(D) prescribe empiric ceftriaxone and azithromycin
(E) start empiric clindamycin
after being found in a confused state at her longterm
care facility. For the past 2 weeks she has been acting
œnot quite herself. According to nursing staff at the
facility, she has had a cough that seems worse during
meals, and occasional low-grade fevers, though no rigors.
Before this episode the patient had been fairly functional
but required physical therapy and nursing for a
recent stroke and resulting left-sided hemiparesis. Vital
signs on time of arrival are temperature of 38.0 C
(100.4 F), blood pressure of 108/68 mm Hg, pulse of
108/min, and respirations of 24/min.An oxygen saturation
obtained with the patient™s vital signs is 85%. The
woman is confused and oriented only to self. She has a
cough and produces some foul-smelling green sputum.
Physical examination is remarkable for inspiratory
crackles heard over the right mid lung zone and right
lung base. Tactile fremitus is increased in this area and
bronchial breath sounds are also present. Laboratory
studies show:
Hematologic
Leukocyte count 20,000/mm3
Neutrophils, segmented 70%
Neutrophils, band 18%
Hematocrit 35%
Platelet count 368,000/mm3
A urinalysis and routine set of chemistries are unremarkable.
A chest radiograph reveals a patchy,
ill-defined opacity in the superior segment of the right
lower lobe, with a small area of central cavitation. Given
this patient™s presentation, the most appropriate treatment
is to
(A) begin trimethoprim/sulfamethoxazole and prednisone
(B) obtain high-resolution CT scan of the lung
© order bronchoscopy with biopsy
(D) prescribe empiric ceftriaxone and azithromycin
(E) start empiric clindamycin