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Order Paper NowInfectious Disease Case Study
CC: L.F. is a 20 year old male college student with a 2-week history of
cough and increased sputum production who presents to your clinic with new chest
pain when he coughs, shortness of breath, intermittent fever and chills and
blood-tinged sputum.
HPI: Cough treated with guiafenesin with dextromethorphan obtained form
roommate
Allergies: sulfa (nausea)
Physical examination:
GEN: DOE and pleuritic chest pain
VS: BP
120/75 HR 95 T 100.5 RR 35 WT 90kg HT 6’4″
CHEST: LUL is CTA with
significantly decreased breath sounds. There are E-to-A changes in the LLL and
across the middle of the right lung field.
COR: tachycardic, no
MRG
HENT: WNL
ABD: WNL
GU: WNL
NEURO: WNL
SKIN: WNL
Chest X-ray: Consolidation of the inferior segments of the LLL. Remainder of
the lungs are clear. Heart size WNL.
Sputum Gram Stain: many WBC, few epithelial cells, moderate gram-positive
cocci in chains and pairs
Questions to Answer:
- Based upon what you learned in class and from your readings, what are the 2
most likely pathogens that would cause pneumonia in this patient? - Based upon your answer to the above question, and the gram stain, what is
the most likely causative microorganism in this patient? - What would you prescribe for this patient to treat his infection, and what
would you tell this patient about those medications (i.e. AE, monitoring of
condition…)? - What other medications would you prescribe for this patient?
- How would you follow-up with this patient (i.e. under what circumstances
would you see him back)?