phuluong2k
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39) 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
Explanation:
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| nisha
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A
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| mani
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A. Chest x-ray film
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| DrS
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A. Chest x-ray film
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| kabu
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CXR
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| ARJ
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B. Sputum Gram's stain
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| alireza501
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A
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| ARJ
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No firm guidelines exist for when to obtain a chest radiograph in patients to aid in diagnosing lower respiratory tract infection. Chest pain, dyspnea, and productive cough are some of the indications used by clinicians. The Infectious Diseases Society of America recommends chest radiography to confirm infiltrates when pneumonia is suspected for the following reasons: The severity of disease may be revealed, detection of pneumonia may not be possible on purely clinical grounds, and antibiotics are not useful for treatment of bronchitis.
Courtesy emedicine.com
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| phuluong2k
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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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| phuluong2k
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Any one has more comment about this ?
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| nisha
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Personally I chose CXR because I got a very very similar question wrong on usmleworld and there the answer was first test should be chest xray, but after doing some research I am even more sure it should be CXR, my reasons are below (toronto notes)
About 30 to 50% of patients have no identifiable pathogen despite a clinical impression of bacterial pneumonia. Although the time-honored method of identifying bacterial pathogens is culturing expectorated sputum, these specimens are often misleading because normal oropharyngeal flora may contaminate them during passage through the upper airways.
Thus, the possibility of staining is almost impossible and extremely tedious and time consuming..why not first get an xray which never takes more then 1/2 hour?
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| DrS
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Yes I have to agree with Nisha, even in practice a CXR is much more practical and rewarding than a sputum for gram stain or culture.
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| phuluong2k
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A 59-year-old man presents to his primary care physician with fever and chills. His past medical history is significant for osteoarthritis for many years. He has a long smoking history of greater than 150 pack-years. He routinely takes only a non-steroidal anti-inflammatory agent for pain. He presents with 5 days of fever and chills associated with a productive cough. He has not been hospitalized recently and lives at home with his wife and has no sick contacts. On physical examination he is comfortable, his temperature is 38.9 C (102 F) and has bibasilar crackles heard best at the left base. Which of the following is the most appropriate next step in diagnosis?
A. Arterial blood gas
B. Chest radiograph
C. Complete blood count
D. Oxygen saturation check
E. Sputum gram stain
Explanation:
The correct answer is
B. The suspicion, based upon the clinical examination, is that this patient has pneumonia. The only way to definitively diagnose pneumonia is with an infiltrate present on chest radiograph. All further decision making about this patient will depend on whether the suspicion of a pulmonary infection is confirmed.
An arterial blood gas (choice A) is not necessary in this situation. These tests are routinely performed on asthmatic and COPD patients when the results are already known empirically. For example, a COPD patient who has a room air saturation of 80% and is tachypneic with labored breathing will almost certainly be hypoxic and hypercarbic. Even if this patient did have a pneumonia, the arterial blood gas will reveal no useful information that an oxygen saturation and thorough history would not.
A complete blood count (choice C) is important, but not before you determine whether this patient has a pneumonia. An elevated leukocyte count can only be interpreted after such information is obtained. This concept is a general one in clinical medicine, never order laboratory tests unless there is specific information sought that may help to confirm or negate a diagnosis.
An oxygen saturation check (choice D) is not appropriate at this point given that the patient's appearance is benign. Hypoxemia would be evident in the patient's respiratory rate, appearance, or his inspiratory effort.
A sputum sample (choice E) is often obtained when a bacterial pneumonia is suspected and selective antibiotic therapy is desired, but the presence of an infiltrate on radiograph would dictate antibiotic therapy based on his age and place of residence (home, hospital, ICU bed). These empiric guidelines are adequate for most therapy and can be tailored to selective therapy based on evolving clinical findings.
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| phuluong2k
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Last time i choose CXR, but this time with a very similar question, i pick sputum gram stain, but the answer is CXR 
So agree with NISHA, i always choose CXR first
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| kabu
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I agree too, clinically thats the norm anyway
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