Question

Case Study #1

CHIEF COMPLAINT: Cough and fever for four days

HISTORY: Mr. Alcot is a 68 year old man who developed a harsh, productive cough four days prior to being seen by a physician. The sputum is thick and yellow.  He developed a fever, shaking, chills and malaise along with the cough. One day ago he developed pain in his right chest that intensifies with inspiration. He lost 15 lbs. over the past few months but claims he did not lose his appetite. "I just thought I had the flu." Past history reveals that he had a chronic smoker's cough for "10 or 15 years" which he describes as being mild, non-productive and occurring most often in the early morning. He smoked 2 packs of cigarettes per day for the past 50 years but has not smoked for 2 years. The patient is a retired truck driver who has been treated for mild hypertension, bronchitis, and splenic injury (motorcycle accident).

PHYSICAL EXAMINATION: The patient is an elderly man who appears tired haggard and underweight. His complexion is pale. He coughs continuously. Sitting in a chair, he leans to his right side, holding his right chest with his left arm. Vital signs are as follows: blood pressure 152/90, heart rate 112/minute and regular, respiratory rate 24/minute and somewhat labored, temperature 102.6F. Both lungs are clear by stethoscope examination with one exception: the right mid-anterior and right mid-lateral lung fields are dull. Auscultation reveals bilateral diminished vesicular breath sounds. Inspiratory crackles are heard in the area of the right mid-anterior and right mid-lateral lung fields. The remainder of the lung fields are clear. Examination of the heart reveals no significant abnormality. Sputum specimen was collected for culture & sensitivity testing. Sputum Gram Stain results are presented below.

Leukocytosis Chest X-Ray

Sputum Gram Stain

LABORATORY: Leukocytosis is present. White Cell Count 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.

COURSE OF ILLNESS: Following a chest x-ray which revealed an acute pneumonia in the right middle lobe, the patient was admitted and treated with IV antibiotics. During the 7 days of treatment the patient's fever abated and he felt somewhat better. He was discharged home with a prescription for the oral version of the same antibiotic he received in the hospital.

1. Identify and explain the significance of physical findings.
2. Review the lab findings. What is your diagnosis?
3. What do you recall from the terms "healthcare" and "community acquired " pneumonia.? Which type of pneumonia does our patient have?
4. What possible organisms could be causing his pneumonia?
5. List the various host factors, or conditions which may have predisposed this patient to pneumonia.
6. What is a primary disadvantage to the examination of expectorated sputum?
7. Looking carefully at the Gram Stain, what antimicrobial agents would you prescribe for this patient? Would you use or avoid penicillin, and why?

******************************************************************************************************************

Case Study #2

A 59 year old man presents with a one day history of fever, abdominal cramps and diarrhea. His symptoms began six hours after the onset of the "runs" in two of his grandchildren and their mother all of whom had been visiting from their dairy and poultry farm in Wisconsin. The day before becoming ill all had eaten a meal consisting of Caesar salad, pasta with stir fried vegetables, bread and apples. His wife prepared her popular homemade mayonnaise.  Other than the abdominal pain and six unformed bowel movements which contained mucus, he had no complaints.

On examination the man appeared ill. Temperature was 39.3 C, pulse 100 and blood pressure 110/80 standing. He had no rash. The abdomen was tender in the periumbilical area. No pain noted otherwise. Laboratory studies presented below.

Stool culture on enteric agar

On examination the man appeared ill. Temperature was 39.3 C, pulse 100 and blood pressure 110/80 standing. He had no rash. The abdomen was tender in the periumbilical area.

WBC                              9.8 X 103 /mm3 Fecal leukocytes              Positive Fecal occult blood           Negative Stool culture is growing motile, lactose non-fermenting, gram rod that is H2S.Positive.

1. What is the likely cause of this man's diarrhea?
2. Do these organisms cause diarrhea by invasion or toxin production?
3. How did the members of the family become infected?  What is the usual route of infection with this pathogen?  
4. What is the preferred therapy for enteritis due to this organism?
5. What measures could be adopted to by this family to reduce the chance of a repeat infection later?

Answer 1

Significant physical findings are

Temperature,blood pressure, respiratory rate,breathing is laboured along with clubbed fingers.

2)lab diagnosis is

Pneumonia and bronchogenic carcinoma.

3)hospital acquired is the infection obtained by a patient in hospital.and community acquired is acquired outside the hospital.And this patient have community acquired pneumonia.

4)As explained above the patient have community acquired pneumonia so organisms causing this are Streptococcus pneumoniae,micoplasma pnuemoniae,hemophillus influenzae, influenza virus.

5) conditions and host factors are smoking,viral respiratory infections, bronchitis and patients with heart,kidney,liver diseases , alcoholism,HIV infections etc

Predisposing factors are mr Alcot is is a long term smoker and has bronchitis which destroy lungs.bronchogenic cancer and splenectomy is also the factors of Mr Alcot.

6)The primary disadvantage is that the sptulum may be contaminated with mouth flora and also with excessive saliva.

7)I would prescribe pencilin as it is a strandard drug used for treating pneumonia and for patients who are allergic to penicillin erythromycin acts as alternative.7 days of antibiotics will trader pneumonia.