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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:
-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.
- Parkinsonism – on carbidopa/levodopa
- Hypertension – stopped taking about 3 weeks ago
- 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
Wbc: 26,000, Neutrophils 90%
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:
- Review the bloodwork findings and how they are significant.
- After Reviewing the CT scan, which lobe is this pulmonary process involved?
- The CT findings is most consistent with what process?
- What are the possible organisms involved in causing this condition
- 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.