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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the common signs, symptoms, physical examination, laboratory, and radiographic findings in a patient with community-acquired pneumonia (CAP).

  • Describe the most common causative pathogens of CAP, including their frequency of occurrence and susceptibility to frequently used antimicrobials.

  • Discuss the risk stratification strategies that can be employed to determine whether a patient with CAP should be treated as an inpatient or outpatient.

  • Provide recommendations for initial empiric antibiotic therapy for an inpatient or outpatient with CAP based on clinical presentation, severity of infection, age, allergies, and comorbidities.

  • Define the goals of antimicrobial therapy for a patient with CAP, as well as the monitoring parameters that should be used to assess the response to therapy and the occurrence of adverse effects.

  • Describe the clinical parameters that should be considered when changing a patient from IV to oral antimicrobial therapy in the treatment of CAP.

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PATIENT PRESENTATION

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Chief Complaint

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“I have been short of breath and have been coughing up rust-colored phlegm for the past 3 days.”

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HPI

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James Thompson is a 55-year-old African-American man with a 3-day history of worsening shortness of breath, subjective fevers, chills, right-sided chest pain, and a productive cough. The patient states that his initial symptom of shortness of breath began approximately 1 week ago after delivering mail on an extremely cold winter day. After several days of not feeling well, he went to an immediate care clinic and received a prescription for levofloxacin 750 mg orally once daily for 5 days, which he did not fill due to financial reasons. He has been taking acetaminophen and an over-the-counter cough and cold preparation, but feels that his symptoms are getting “much worse.” The patient began experiencing right-sided pleuritic chest pain and a productive cough with rust-colored sputum over the past 3 days, and feels that he has been feverish with chills, although he did not take his temperature. On presentation to the ED, he is febrile and appears visibly short of breath.

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PMH

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  • Hypertension × 15 years

  • Type 2 diabetes mellitus × 10 years

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SH

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  • Lives with wife and four children

  • Employed as a mail carrier for the US Postal Service

  • Denies alcohol, tobacco, or intravenous drug use

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Home Medications

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Prescription
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  • Patient states that he only sporadically takes his medications due to financial reasons

  • Lisinopril 10 mg orally once daily

  • Hydrochlorothiazide 25 mg orally once daily

  • Metformin 1000 mg orally twice daily

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Over-the-Counter
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  • Acetaminophen 650 mg orally every 6 hours as needed for pain

  • Guaifenesin/dextromethorphan (100 mg/10 mg/5 mL) two teaspoonfuls every 4 hours as needed for cough

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All

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