Case Presentation: 66 year old with persistent cough after 3 weeks ago

In keeping with the recent post on pneumonia, here is a case challenge of a patient with a pulmonary process:

66 year old with a history of Parkinsonism, ongoing tobacco dependence developed head congestion, fevers and cough reports to the Emergency Department:

History:

-3 weeks ago, symptoms began with cough and fevers

-2 weeks ago, urgent care visit – felt to have a viral syndrome – did not improve

-1 week ago, urgent care visit – prescribed azithromycin for possible pneumonia

-ongoing productive cough, worse at night with on/off subjective fevers and sweats

ROS:  Some nausea and vomiting night before going to the hospital, some diarrhea after azithromycin.  Mild dyspnea.  No hemoptysis (blood in sputum)   No recent travel. 

PMHx:

  1. Parkinsonism – on carbidopa/levodopa
  2. Hypertension – stopped taking about 3 weeks ago
  3. Tobacco dependence

All:  Penicillin – as a child – may have had a rash.

Social:  Smokes 1 1/2 packs per day.  No illicit drug; occasional marijuana

Physical exam:  T 98.6, HR 102, BP 156/85, RR 18, Pulse ox 95% Room air

  • Gen: A/o x 3, cachectic-appearing, no acute distress
  • HEENT:  Moist membranes.  Mask facies
  • Neck:  Shotty posterior cervical lymph nodes
  • Chest:  Diminished breath sounds throughout, coarse crackles in the left base.  No wheeze.
  • Heart:  Regular rate and rhythm, no murmurs, rubs or gallops.
  • Abdomen;  Soft, thin, mild periumbilical tenderness, no rebound or rigidity
  • Ext: Warm, well perfused.  No evidence of cutaneous septic emboli.
  • Neuro:  Resting tremor of hands, cogwheel rigidity noted or arms

Bloodwork:

Wbc: 26,000,  Neutrophils 90%

H/H:  11/32

Platelet:  817

Chemistries:  Sodium: 130,  Potassium 3.3, BUN/Cre 20/1.1, Chloride 91

Alb 2.8, Protein 6.1, LFT: normal 

CXR upon presentation:

CT scan findings:

Sagittal Section
Coronal view

Questions:

  1. Review the bloodwork findings and how they are significant.
  2. After Reviewing the CT scan, which lobe is this pulmonary process involved?
  3. The CT findings is most consistent with what process?
  4. What are the possible organisms involved in causing this condition
  5. What would be a good empirical therapy to begin on this patient?

The Answers to these questions as well as an update on the case will be presented in a later post this week.

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