Question

A 80-year-old man presents to the emergency department (ED) complaining of right-sided chest pain when he breathes and a productive cough. A sputum sample collected revealed rust-colored sputum. He also states that his symptoms began abruptly with chills the day before this visit to the ED; he had previously been healthy. Examination by the physician identifies coarse breathing sounds in the right anterior chest. A chest radiograph shows a right upper lobe infiltrate. The patient currently has a fever of 102°F. Blood is drawn for a CBC. The sputum sample is Gram-stained and cultured. Laboratory data follow:

Complete Blood Count

Hemoglobin: 14.5 g/dL (normal)

White blood count: Elevated

Differential: 90% neutrophils (normal range 25%-60%)

Sputum

Gram stain: Gram-positive lancet-shaped diplococci (cocci in pairs)

Culture report: Streptococcus pneumoniae

The diagnosis is pneumonia caused by S. pneumoniae.

Critical Thinking Questions

1. What clinically relevant signs and symptoms support the diagnosis?

2. What laboratory findings support the diagnosis?

Answer 1

1. Relevant signs of pneumonia

• Right sided chestpain
• Productive cough
• Hemoptysis
• Chills
• Dyspnea
• Fever
• Horse breathing sound in auscultation

2. Laboratory findings

• WBC elevated
• Neutrophilia
• Sputum :Gram stain: Gram positive Lancet shaped diplococci
• Culture report confirms the diagnosis
• Microscopic examination findings