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LEARNING OBJECTIVES

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

  • 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

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.

PMH

  • Hypertension × 15 years

  • Type 2 diabetes mellitus × 10 years

SH

  • Lives with wife and four children

  • Employed as a mail carrier for the US Postal Service

  • Denies alcohol, tobacco, or intravenous drug use

Home Medications

Prescription

  • 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

Over-the-Counter

  • Acetaminophen 650 mg orally every 6 hours as needed for ...

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