Question

A 55-year-old male presents to his primary care physician's office with cough, mild dyspnea, and fever to 101 degrees. Symptoms have been present for the past 3 days, and when over-the-counter cold medications were having no effect, he decided to seek medical attention. On initial examination, blood pressure was 120/73, pulse was 96 and regular, and respirations were 20. He was febrile with a temperature of 100.9 degrees. Lung examination revealed the presence of right lower lung crackles with decreased breath sounds in this area as well. Laboratory studies revealed WBC of 15.6 with a left shift, sodium of 140, potassium of 4.5, BUN of 22 and creatinine of 1.0. Chest x-ray revealed a right lower lobe infiltrate. Based upon the above presentation, what is the most appropriate course of action?

Answer 1

By the results of lab tests and chest X-ray it is evident that patient has pneumonia. It is most likely a case of community acquired pneumonia. Based upon the presentation of symptoms, the patient does not require hospital admission but pneumonia severity index scale can be used to decide whether hospital admission is necessary or not. Based on above presentation the patient should be prescribed appropriate antibiotics ( clarithromycin or azithromycin or ciprofloxacin, levofloxacin) and sent home. The patient should be advised to come back for re-evaluation in a week and should be examined for improvements. If the patient is not showing any improvement or if his condition is deteriorating, he should be hospitalized.

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