Hotobhaga
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24) 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.
Look at this now… Same Q_Bank different block
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:
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.
How can you do this?
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| ssrpk
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well heres a discrepancy....
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| elitoki
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I think the differences were:
* the first question sounds like atypical pneumonia, and Mycoplasma pneumoniae is the most freq. agent to cause it. Neither Gram nor Culture will help to diagnose mycoplama pneumonia. so Chest X ray will be the best answer.
* In the second question is typical pneumonia that should be conform by Gram and Culture. Usually doing the gram, we will be able to begin the treatment so in this case the answer was Gram. Strep pneumonia is the most common agent on typical pneumonia.
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| hanialkhadher
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i noticed this Q too, i think the 1st chest investigation should be CXR, but i think people who made qs in kaplan and UW dont give it enough work to avoid these mistakes
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| cirus
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Typical or atypical pneumonia,
the first step has to be an x ray
I think its a mistake
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| young_doc
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Pneumonia is NEVER a clinical diagnosis. CXR should always be done first.
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| Justice
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elitoki wrote:I think the differences were: * the first question sounds like atypical pneumonia, and Mycoplasma pneumoniae is the most freq. agent to cause it. Neither Gram nor Culture will help to diagnose mycoplama pneumonia. so Chest X ray will be the best answer. * In the second question is typical pneumonia that should be conform by Gram and Culture. Usually doing the gram, we will be able to begin the treatment so in this case the answer was Gram. Strep pneumonia is the most common agent on typical pneumonia.
Q1 does not sound like atypical pneumonia. the Pt has fever, chills, and productive cough (main argument against Atypical pn-a)...
What is common between the above cases is that in both of them the diagnosis can be made by CXR. This would be true for any pn-a... At the same time, the sputum microbioanalysis will work only for those who have collectible sputum... For some atypicals, like PCP, only bronchial lavage will help...
So, I would go with CXR in any pn-a presentation...
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| ssrpk
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i agree with you guys
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| elitoki
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Thanks Justice~
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