Chapter 119: Community-Acquired Pneumonia: The Coughing Conundrum Level II

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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, conversion from IV to PO therapy (where warranted), and the occurrence of adverse effects.

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. He has been taking ibuprofen 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 visibly short of breath.

PMH

Hypertension × 15 years

Dyslipidemia × 15 years

Type 2 diabetes mellitus × 10 years

FH

Adopted; unknown birth parents

SH

Lives with wife and four children

Employed as a mail carrier for the US Postal Service

Denies alcohol, tobacco, or intravenous drug use

Medications

Prescription

Lisinopril 10 mg orally once daily

Hydrochlorothiazide 25 mg orally once daily

Atorvastatin 20 mg orally once daily

Metformin 1000 mg orally twice daily

Over-the-Counter

Ibuprofen 200 mg PO Q 6 H as needed for pain and fever

Guaifenesin/dextromethorphan (100 mg/10 mg/5 mL) two ...