docnikki
Forum Guru
Topics: 93
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A 70-year-old woman has been brought to the emergency department for shortness of breath, cough, and lethargy for one day. The patient is confused. The daughter denies any problem of this type with the patient in the past, but she says cancerous polyps were found last year on colonoscopy. There has been progressive confusion and deterioration in her mental status over several years. On physical examination, the patient was found to be confused and has a temperature of 101 F, a blood pressure of 85/60 mm Hg, a pulse of 120/min, and a respiratory rate of 28/min. The chest examination shows decreased breath sounds with dullness to percussion on the right side at the base. The cardiac examination is normal. Laboratory studies reveal: white cell count 12,000/mm3, hematocrit 28%, platelets 400,000/mm3, sodium 135 mEq/L, bicarbonate 20 mEq/L, BUN 60 mg/dL, creatinine 3 mg/dL, and glucose 110 mg/dL. Urinalysis is positive for protein. Chest x-ray shows a right lower lobe infiltrate. Which of the following is correct about this patient?
(A) She has an approximately 30% chance to die with in 30 days
(B) Bronchoscopy is required
(C) The chance for Streptococcus pneumonia to be isolated is 80%
(D) Start ciprofloxacin
E) Start vancomycin
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| farnsworth
Forum Newbie
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The patient most likely suffers from aspiration (H/o altered mental state)
-> bronchoscopy
if particulate matter is seen and the patient shows clinical signs of aspiration (fever, elevated WBC, infiltrate on CXR) -> antibiotic therapy (2nd generation cephalosporin + metronidazole, or 3rd gen cephalosporing + clindamycin, or ureidopenicillin + betalactamase inhibitor; if aspiration of bowel content (ileus): carbapeneme + metronidazole).
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| Korotkoff
Forum Senior
Topics: 14
Posts: 164
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Can this be Legionella Pneumonia?
I will go with D.
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| doc_clotaire
Forum Guru
Topics: 159
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Legionnaire Disease seems to be a good bet
SOB , cough , lehargy , confusion , boderline hyponatremia and renal failure in old patients could fit this disease pretty well .
D ......................
___________________
The elevator to succes is broke ,you must take the stairs
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| farnsworth
Forum Newbie
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If it was legionella, the patient would have a 25-30% chance to die even with therapy (so (A) would fit, too).
Nevertheless, the vignette fits legionella.
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| docnikki
Forum Guru
Topics: 93
Posts: 680
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none of you got this one..
its A.
The Pneumonia Outcome Research Team (PORT) scoring system is used to assess the risk of mortality on the basis of 19 clinical variables. The system stratifies patients into five mortality risk classes. This patient, with a score of >130, falls within the risk class V, which has a mortality risk between 27 and 31%. The following are the clinical variables for this patient and their scoring:
Age 70 (women: age - 10) = 60
Renal disease = 10
Hematocrit <30% = 10
Pleural effusion = 10
BUN >30 mg/dL = 20
Systolic pressure <90 mm Hg = 20
Neoplasm = 30
Total = 160
Patients with this class of mortality risk definitely need hospitalization. Streptococcus pneumoniae is the most common organism to be isolated in adults, but it is isolated in far less than 80% of cases. Prospective studies fail to identify a specific microbiologic cause of community-acquired pneumonia (CAP) in >50% of cases. Sputum Gram stain and culture should be done on all patients who are hospitalized. Bronchoscopy is not necessary unless the patient is severely ill, and sputum analysis fails to identify a specific causative organism. Ciprofloxacin is not an appropriate choice of medication for CAP; it has inadequate pneumococcal coverage. Vancomycin is used in pneumonia only if the causative organism has been definitely identified as penicillin-resistant pneumococcus. The other criteria for a serious pneumonia are: the presence of liver or heart disease, a pulse of >125/min, a sodium of <130 mEq/L, a glucose of >250 mEq/L, a pO2 of <60 mm Hg, a fever >40 C, and confusion
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| pr20
Forum Senior
Topics: 18
Posts: 161
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D.
Yes,clinical picture seems to be like Legionnaire's disease and treatment should be started as soon as the disease is suspected bcas mortality rate can increase with starting the treatment late.
Start treatment immediately with fluoroquinolones or macrolides.
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| sherry39
Forum Junior
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Posts: 105
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a....coz it is due to metastasis of cancer causing CNS n lung involvement leadig to SIRS and renal failure.hb is low showing FOB would be +ve if checked
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