Lower Respiratory Tract Infections Flashcards
- Which of the following statements regarding the epidemiology of community-acquired pneumonia is correct?
A. Mycoplasma pneumoniae is the most prevalent bacterial pathogen.
B. Haemophilus influenzae is a common pathogen in adults who smoke tobacco.
C. Necrotizing CAP which is common in children is caused by CA-MRSA and
associated with a high (42%) mortality rate.
D. Mixed infections with bacteria and viruses are an uncommon cause of CAP in
adults, incidence less than 5%.
B
- AJ is a 52-year-old man admitted to the hospital with suspected aspiration pneumonia. His home medications are lisinopril 20 mg once daily and omeprazole 20 mg once daily. What organisms need to be considered as causative agents in AJ?
A. Staphylococcus aureus, Escherichia coli, and viridans Streptococci
B. Anaerobes, E. coli, and viridans Streptococci
C. S. aureus and anaerobes
D. Anaerobes and Streptococcus pneumoniae
E. Anaerobes, viridians Streptococci, Streptococcus pneumoniae, E. coli, and S.
aureus
B
- CD is a 66-year-old woman admitted to the hospital for respiratory failure. Upon
admission she was intubated. She was improving and on day 9 was starting to be weaned off the ventilator. On day 9 her respiratory symptoms were worsening and full ventilator settings were required. She is diagnosed with ventilator-associated pneumonia. Which of the following organisms are most likely associated with her pneumonia?
A. S. pneumoniae, H. influenzae, MRSA, and MSSA
B. H. influenzae, enteric GNB, anaerobes, and MSSA
C. Pseudomonas aeruginosa, Acinetobacter spp., and MRSA
D. S. pneumoniae, H. influenzae, viridians Streptococci, and MRSA
E. P. aeruginosa, Acinetobacter spp., anaerobes, and S. pneumoniae
C
- PF is a 50-year-old man who smokes two packs of cigarettes per day. Which of the
following host defenses that protect the lung are known to be impaired by the smoke?
A. Mucous and ciliated cells
B. Alveolar macrophages
C. Immunoglobulin (IgA, IgG, and IgM)
D. A and C
E. All of the above
A
- GH is a 58-year-old woman who presents to the emergency room complaining of a
productive cough (greenish/yellowish stuff) and chest tightness. She states this feels
different from her usual cough. Two weeks earlier, she had developed a cold, which was resolving prior to the onset of the current symptoms. For the last week she babysat her 2- year-old grandson who had an ear infection and could not attend his daycare.
PMH: COPD 6 years
Allergies: cephalosporins—hives, shortness of breath
SH: smoked 2-ppd 10 years, quit 2 years ago, lives with her husband (nonsmoker)
Vitals: 100.8°F (38.2°C), HR 80, 118/86 Pulse Ox: 82% (0.82) on room air
PE: Lungs: rales, rhonchi, decreased breath sounds over right mid lobe
Chest x-ray: right mid lobe infiltrate
Sputum Gram stain: Moderate WBCs, no organisms seen
What signs, symptoms, and risk factors does GH have that are associated with
community acquired pneumonia?
A. Cough, shortness of breath, difficulty breathing, rales, rhonchi, decreased breath
sounds, chest x-ray findings
B. Fever, myalgias, mental status changes, cough, low oxygenation, exposure to
grandson, chest x-ray findings, chest tightness
C. Chest x-ray findings, cough, fever, shortness of breath, rales, rhonchi, decreased breath sounds, chest tightness
D. Cough, rales, rhonchi, decreased breath sounds, low oxygenation, chest tightness,
fever, exposure to grandson
E. Cough, rales, rhonchi, decreased breath sounds, low oxygenation, chest tightness,
fever, chest x-ray findings, exposure to grandson
E
- Immune responses to pneumonia include the following:
A. Alveolar macrophages engulfing organisms attempting to contain the infection
B. Cytokine release from macrophages increasing mucous production
C. Alveolar macrophages engulfing organisms and presenting the antigens to elicit an adaptive immune response
D. A and C
E. All of the above
E
- GH is a 58-year-old woman who presents to the emergency room complaining of a
productive cough (greenish/yellowish stuff) and chest tightness. She states this feels
different from her usual cough. Two weeks earlier, she had developed a cold, which was resolving prior to the onset of the current symptoms. For the last week she babysat her 2- year-old grandson who had an ear infection and could not attend his daycare.
PMH: COPD 6 years
Allergies: cephalosporins—hives, shortness of breath
SH: smoked 2-ppd 10 years, quit 2 months ago, lives with her husband (nonsmoker)
Vitals: 100.8°F (38.2°C), HR 80, 118/86 Pulse Ox: 82% (0.82) on room air
PE: Lungs: rales, rhonchi, decreased breath sounds over right mid lobe
Chest x-ray: right mid lobe infiltrate
Sputum Gram stain: Moderate WBCs, no organisms seen
What factors need to be considered before empirical therapy for CAP can be selected for GH?
A. COPD and quit smoking 2 months ago
B. Chest x-ray—right mid lobe infiltrate and decreased breath sounds over right mid
lobe
C. Allergy to cephalosporins
D. A and C
E. All of the above
D
- Which of the following statements regarding resistance is paired to the appropriate organism?
A. The absence of a cell wall results in resistance to β-lactams for Moraxella
catarrhalis.
B. β-Lactamase production confers resistance to penicillin for S. pneumoniae
C. Methylation of ribosomes confers clarithromycin resistance for S. pneumoniae
D. β-Lactamase production within H. influenzae has steadily increased over the past 10 years with rates now over 70%
C
- JF is a 60-year-old woman presents to the emergency room complaining of a productive cough (greenish/yellowish stuff) and chest tightness.
PMH: HTN 4 years. Vitals:
101.2°F (38.4°C), HR 80, 118/86, respiratory rate 18, pulse oximetry (oxygen saturation)
96% (0.96) on room air. Ht 5’5” (165 cm) Wt 140 lbs (63.6 kg). Allergies: NKDA. Home
medication is atenolol 50 mg once daily. Chest x-ray: right mid lobe infiltrate. She is alert and oriented × 3. Her electrocardiogram is normal, renal function is normal (creatinine clearance 75 mL/min [1.25 mL/s]), and WBCs are 11.8 cells/mm3
(11.8 106/L).
Which of the following would be the most appropriate empirical therapy for JF’s
pneumonia?
A. Azithromycin 500 mg PO every 24 hours
B. Levofloxacin 750 mg PO every 24 hours
C. Ceftriaxone 1 g IV plus azithromycin 500 mg IV every 24 hours
D. Cefepime 2 g IV plus doxycycline 100 mg IV q12h
A
- DR is a 72-year-old man who presented to the hospital for a hernia repair. PMH is
significant for smoking for the last 20 years. He has been intubated for the last 12 days, and attempts to wean DR off of the ventilator failed. The nurses noted increased volume and purulence of secretions from the ventilator. Chest x-ray: left lower lobe infiltrate. Urinary DFA for Legionella is negative. Ht 5’10” (178 cm) Wt 75 kg and he has NKDA.
PMH is negative, and home medications are 1 multivitamin once daily. Creatinine
clearance is 70 mL/min (1.17 mL/s), WBCs are 13.5 cells/mm3 (13.5 106
/L), and temperature is 100.4°
F (38.0°C).
Which of the following organisms are the most likely pathogens for DR’s pneumonia?
A. MRSA, extended-spectrum β-lactamase–producing Klebsiella pneumoniae, P.
aeruginosa, Acinetobacter spp.
B. S. pneumoniae, MSSA, E. coli, K. pneumoniae
C. Anaerobes, viridans Streptococci, E. coli, K. pneumoniae
D. S. pneumoniae, H. influenzae, M. catarrhalis, M. pneumoniae, C. pneumoniae, and Legionella pneumophila
A
- DR underwent bronchoscopy, and the Gram stain of the bronchoalveolar lavage shows moderate gram-positive cocci in clusters, moderate gram-negative bacilli, and many WBCs. Which of the following would be the most appropriate empirical regimen for DR’s pneumonia?
A. Moxifloxacin 400 mg IV or PO every 24 hours plus vancomycin 1500 mg IV
every 12 hours plus cefepime 2 g IV every 12 hours
B. Nafcillin 2 g IV every 6 hours plus cefepime 2 g IV every 12 hours plus
tobramycin 380 mg IV every 24 hours
C. Vancomycin 1500 mg IV every 12 hours plus cefepime 2 g IV every 12 hours
plus tobramycin 380 mg IV every 24 hours
D. Azithromycin 500 mg IV every 24 hours plus ceftriaxone 1 g IV every 24 hours
E. Ertapenem 1 g IV every 24 hours plus ceftriaxone 1 g IV every 24 hours
C
- Which of the following factors is/are the most important considerations for determining the duration of therapy for DR?
A. Clinical pulmonary infection score
B. Time to the start of clinical improvement
C. Risks for toxicity associated with the therapy
D. A and C
E. All of the above
A
- Which of the following are appropriate outcome evaluations for pneumonia?
A. Improvement of symptoms within 48 to 72 hours for HAP, HCAP, and VAP
B. Resolution of symptoms within 96 to 120 hours for HAP, HCAP, and VAP
C. Improvement of symptoms within 48 to 72 hours for CAP
D. Resolution of symptoms within 48 to 72 hours for CAP
C
- CC is a 24-year-old woman inquiring about the receiving the influenza and
pneumococcal vaccines at your pharmacy. She has asthma, has no drug or food allergies, and is 6 months pregnant. Which of the following vaccines can she receive?
A. Fluzone intradermal
B. Influenza intranasal
C. 13-valent conjugated pneumococcal
D. 7-valent conjugated pneumococcal
E. None, she has to wait until after the pregnancy to be vaccinated
A
- AK is a 12-year-old child who will have to undergo a splenectomy. In order to minimize pneumococcal disease after the splenectomy, AK should receive:
A. The polysaccharide vaccine
B. The 13-valent conjugated vaccine
C. No vaccine because they are not effective in the absence of a spleen and AK
should be placed on penicillin prophylaxis to prevent pneumococcal disease
A
- Which of the following statements regarding the epidemiology of community-acquired pneumonia is correct?
A. Streptococcus pneumoniae and Mycoplasma pneumoniae are the most prevalent pathogens.
B. Influenza virus is a common pathogen in adults who smoke tobacco.
C. Necrotizing CAP, which is common in children, is caused by CA-MRSA and
associated with a high (42%) mortality rate.
D. Mixed infections with bacteria and viruses are an uncommon cause of CAP in
adults, incidence less than 5%.
A
- KM is a 46-year-old woman admitted to the hospital secondary to a motor vehicle
accident. On day 4 of hospitalization, she started to cough, had shortness of breath, and a temperature of 101F (38.3C). Chest X-ray revealed a left mid lobe infiltrate. She was diagnosed with hospital-acquired pneumonia. She has no chronic health conditions and takes no prescription medications. Which of the following organisms are most likely associated with her pneumonia?
A. S. pneumoniae, MSSA, E. coli, K. pneumoniae
B. Mycoplasma pneumoniae, E. coli, K. pneumoniae, anaerobes, and MSSA
C. Pseudomonas aeruginosa, Acinetobacter spp., and MRSA
D. P. aeruginosa, Acinetobacter spp., anaerobes, and S. pneumoniae
A
- PF is a 59-year-old woman who presents to your clinic with complaints of coughing,
shortness of breath, and chest tightness. Her chest X-ray reveals a right mid lobe
infiltrate. Her respiratory rate is 16 breaths/min, pulse 82 beats/min, and O 2 saturation on room air 94%. She is diagnosed with community-acquired pneumonia. PF does not smoke and her only medication is lisinopril for hypertension. She has NKDA. Macrolide
resistant pneumococci in your community is 30%. Which of the following would be the
most appropriate therapy you could recommend for treating PF’s pneumonia?
A. Amoxicillin/clavulanate 875/125 mg orally twice daily
B. Levofloxacin 750 mg orally once daily
C. Azithromycin 500 mg orally once then 250 mg orally once a day
D. Amoxicillin 1 g orally three times daily
D
- JZ is a 64-year-old woman who presents to the emergency room complaining of a
productive cough (greenish/yellowish stuff) and chest tightness. She states this feels
different from her usual cough. Two weeks earlier, she had developed a cold, which was resolving prior to the onset of the current symptoms. For the last week, she babysat her 2-year-old grandson who had an ear infection and could not attend his daycare.
PMH: COPD 6 years
Allergies: cephalosporins—hives, shortness of breath
SH: smoked 2-ppd 16 years, quit 2 years ago, lives with her husband
(nonsmoker)
Vitals: 100.8F (38.2C), HR 80, 118/86, respiratory rate 16 breaths/minute, Pulse
Ox: 82% (0.82) on room air
PE: Lungs: rales, rhonchi, decreased breath sounds over right mid lobe
Chest X-ray: right mid lobe infiltrate
Sputum Gram stain: Moderate WBCs, no organisms seen
Which of the following provides all of the signs and symptoms JZ has that are associated with community-acquired pneumonia?
A. Cough, respiratory rate, difficulty breathing, rales, rhonchi, decreased breath
sounds, low oxygenation, chest X-ray findings
B. Cough, rales, rhonchi, decreased breath sounds, low oxygenation, chest tightness,
fever, chest X-ray findings
C. Chest X-ray findings, cough, fever, shortness of breath, rales, rhonchi, decreased
breath sounds, chest tightness
D. Cough, rales, rhonchi, decreased breath sounds, low oxygenation, chest tightness,
fever, increased WBCs in blood
B
- Which of the following statements regarding resistance is paired to the appropriate organism?
A. The absence of a cell wall results in resistance to β-lactams for Moraxella
catarrhalis.
B. Altered PBPs confer resistance to penicillin for S. pneumoniae.
C. Ribosome changes via the tetM gene confer clarithromycin resistance for S.
pneumoniae.
D. β-Lactamase production within H. influenzae has steadily increased over the past 10 years with rates now over 70%.
C
- If a person inhales viral containing droplets 11 µm in size what is the likelihood of the particles getting to the alveolar sacs and pneumonia developing?
A. High likelihood, particles this size are small enough to evade local host defenses.
B. Low likelihood, particles>10 µm are efficiently trapped in the upper airway and
removed.
C. Moderate likelihood, particles in the range of 5 to 12 µm are trapped by the
mucociliary apparatus at a rate of about 50%, leaving 50% to enter the alveolar
sacs.
B
- DR is a 72-year-old man who presented to the hospital for a hernia repair. Following the surgical repair, the medical team is unable to wean him off of the ventilator. He has been intubated for the last 5 days. The nurses noted increased volume and purulence of secretions from the ventilator.
DR is 5’1 and weighs 75 kg and has Medicare.
PMH: COPD × 10 years, HTN × 35 years, BPH × 6 years, chronic kidney disease
(CKD) × 12 years
Vitals: 100.8F (38.2C), HR 90, 110/70
Chest X-ray: left lower lobe infiltrate
Allergies: penicillins and cephalosporins—hives, tongue swelled up;
erythromycin—GI upset; sulfamethoxazole/trimethoprim—skin peeling and blisters
Laboratory results: Urinary DFA for legionella is negative
Creatinine clearance is 30 mL/min (0.5 mL/s), WBCs are 13.5 cells/mm 3 (13.5
10 6 /L), and temperature is 100.4F (38.0C).
Which of the following factors for this case will impact the therapeutic regimen selection process?
A. COPD, CKD, allergies, intubation
B. COPD, HTN, CKD, allergies, age, intubation
C. COPD, HTN, BPH, CKD, allergies
D. COPD, CKD, allergies, age, urinary DFA
A
- DR (from question 7) had sputum sent to the laboratory for culture and susceptibility
analysis. The Gram stain revealed moderate Gram-positive cocci in clusters, moderate Gram-negative bacilli, and many WBCs. Which of the following would be the most appropriate empirical regimen for DR’s pneumonia?
A. Moxifloxacin 400 mg IV every 24 hours plus vancomycin 1500 mg IV every 24
hours plus aztreonam 1 g IV every 8 hours
B. Linezolid 600 mg IV every 12 hours plus cefepime 2 g IV every 24 hours plus
tobramycin 130 mg IV every 24 hours
C. Ertapenem 1 g IV every 24 hours plus linezolid 600 mg IV every 12 hours plus
ceftazidime 2 g IV every 12 hours
D. Vancomycin 1500 mg IV every 24 hours plus aztreonam 1 g IV every 8 hours
plus tobramycin 130 mg IV every 24 hours
D
- DR (from question 7) was improving clinically within 48 hours of initiating antimicrobial therapy. It is now 96 hours after the start of therapy and he continues to improve. At this time your planned total duration of therapy for DR should be:
A. 7 days
B. 10 days
C. 14 days
D. 21 days
A
- CC is a 69-year-old woman inquiring about the receiving the influenza and
pneumococcal vaccines at your pharmacy. Her last vaccine was 8 years ago, she received the Shingrix vaccine. She has asthma, has no drug or food allergies and has never had pneumonia. Based on her characteristics and the Center for Disease Control recommendations, which of the following vaccines should she receive? (Select all that apply)
A. Fluzone™
B. Fluzone™ high dose
C. 13-valent conjugated pneumococcal
D. 23-valent polysaccharide pneumococcal
B, D
GH is a 73-year-old woman presents to your ED on June 20th complaining of difficulty breathing and shortness of breath. Her physical examination reveals that she is confused and disoriented, has decreased breath sounds on the left side compared with the right, and has rales in the left lower lobe. Her temperature is 37.4C, respiratory rate is 30 breaths
per minute, and blood pressure is 90/65 mm Hg.
PMH Hypertension for 4 years, currently controlled
FH: Father died of lung cancer at the age of 68 years; mother died of natural causes.
SH: Smoked 1 pack per day for 5 years, quit 35 years ago. Does not drink alcohol.
She lives with her daughter.
Allergies: NKDA Height: 53 Weight: 165 pounds
Meds: Lisinopril 10 mg PO qd
ROS: (+) difficulty breathing and shortness of breath; (−) chest pain, N/V/D, weight
loss, change in appetite
PE: VS: BP 90/65, P 98, RR 30, T 37.4C
CV: RRR, normal S1, S2; no murmurs, rubs, or gallops
Lungs: Decreased breath sounds on the left side compared with the right and rales in the left lower lobe, breaths are shallow.
Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly, heme (−) stool
Neuro: Oriented to name and place but not to date. She is easily confused by
questions asked of her.
Diagnostic Tests
Chest X-ray: left lower lobe infiltrates
Oxygen saturation 82% on room air
Labs: Na 145, K 4.1, Cl 100, CO2 26, Glu 160, BUN 23, sCr 1.3 WBCs 12.8, Hgb
10.2, Hct 31.1, Plts 310
- What patient factors need to be considered before empirical therapy for GH’s pneumonia can be selected? (select all that apply)
A. Renal function
B. Chest X-ray—right mid lobe infiltrate and decreased breath sounds over right mid
lobe
C. No known drug allergies
D. Oxygen saturation 82%
A, C
GH is a 73-year-old woman presents to your ED on June 20th complaining of difficulty breathing and shortness of breath. Her physical examination reveals that she is confused and disoriented, has decreased breath sounds on the left side compared with the right, and has rales in the left lower lobe. Her temperature is 37.4C, respiratory rate is 30 breaths
per minute, and blood pressure is 90/65 mm Hg.
PMH Hypertension for 4 years, currently controlled
FH: Father died of lung cancer at the age of 68 years; mother died of natural causes.
SH: Smoked 1 pack per day for 5 years, quit 35 years ago. Does not drink alcohol.
She lives with her daughter.
Allergies: NKDA Height: 53 Weight: 165 pounds
Meds: Lisinopril 10 mg PO qd
ROS: (+) difficulty breathing and shortness of breath; (−) chest pain, N/V/D, weight
loss, change in appetite
PE: VS: BP 90/65, P 98, RR 30, T 37.4C
CV: RRR, normal S1, S2; no murmurs, rubs, or gallops
Lungs: Decreased breath sounds on the left side compared with the right and rales in the left lower lobe, breaths are shallow.
Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly, heme (−) stool
Neuro: Oriented to name and place but not to date. She is easily confused by
questions asked of her.
Diagnostic Tests
Chest X-ray: left lower lobe infiltrates
Oxygen saturation 82% on room air
Labs: Na 145, K 4.1, Cl 100, CO2 26, Glu 160, BUN 23, sCr 1.3 WBCs 12.8, Hgb
10.2, Hct 31.1, Plts 310
- What are the two most common organisms that you need to cover with your empirical antibiotic therapy for GH’s pneumonia?
A. Streptococcus pneumoniae and Haemophilus influenzae
B. Influenza A and Mycoplasma pneumoniae
C. Chlamydia pneumoniae and Streptococcus pneumoniae
D. Streptococcus pneumoniae and Mycoplasma pneumoniae
D
GH is a 73-year-old woman presents to your ED on June 20th complaining of difficulty breathing and shortness of breath. Her physical examination reveals that she is confused and disoriented, has decreased breath sounds on the left side compared with the right, and has rales in the left lower lobe. Her temperature is 37.4C, respiratory rate is 30 breaths
per minute, and blood pressure is 90/65 mm Hg.
PMH Hypertension for 4 years, currently controlled
FH: Father died of lung cancer at the age of 68 years; mother died of natural causes.
SH: Smoked 1 pack per day for 5 years, quit 35 years ago. Does not drink alcohol.
She lives with her daughter.
Allergies: NKDA Height: 53 Weight: 165 pounds
Meds: Lisinopril 10 mg PO qd
ROS: (+) difficulty breathing and shortness of breath; (−) chest pain, N/V/D, weight
loss, change in appetite
PE: VS: BP 90/65, P 98, RR 30, T 37.4C
CV: RRR, normal S1, S2; no murmurs, rubs, or gallops
Lungs: Decreased breath sounds on the left side compared with the right and rales in the left lower lobe, breaths are shallow.
Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly, heme (−) stool
Neuro: Oriented to name and place but not to date. She is easily confused by
questions asked of her.
Diagnostic Tests
Chest X-ray: left lower lobe infiltrates
Oxygen saturation 82% on room air
Labs: Na 145, K 4.1, Cl 100, CO2 26, Glu 160, BUN 23, sCr 1.3 WBCs 12.8, Hgb
10.2, Hct 31.1, Plts 310
- GH is intubated and admitted to the medical intensive care unit. What is the most appropriate therapy you can recommend for GH’s pneumonia?
A. Ceftriaxone 1 g IV q24h plus levofloxacin 500 mg PO q24h
B. Ceftriaxone 1 g IV q24h
C. Ciprofloxacin 500 mg PO q12h
D. Azithromycin 500 mg PO × 1 then 250 mg PO q24h
A
GH is a 73-year-old woman presents to your ED on June 20th complaining of difficulty breathing and shortness of breath. Her physical examination reveals that she is confused and disoriented, has decreased breath sounds on the left side compared with the right, and has rales in the left lower lobe. Her temperature is 37.4C, respiratory rate is 30 breaths
per minute, and blood pressure is 90/65 mm Hg.
PMH Hypertension for 4 years, currently controlled
FH: Father died of lung cancer at the age of 68 years; mother died of natural causes.
SH: Smoked 1 pack per day for 5 years, quit 35 years ago. Does not drink alcohol.
She lives with her daughter.
Allergies: NKDA Height: 53 Weight: 165 pounds
Meds: Lisinopril 10 mg PO qd
ROS: (+) difficulty breathing and shortness of breath; (−) chest pain, N/V/D, weight
loss, change in appetite
PE: VS: BP 90/65, P 98, RR 30, T 37.4C
CV: RRR, normal S1, S2; no murmurs, rubs, or gallops
Lungs: Decreased breath sounds on the left side compared with the right and rales in the left lower lobe, breaths are shallow.
Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly, heme (−) stool
Neuro: Oriented to name and place but not to date. She is easily confused by
questions asked of her.
Diagnostic Tests
Chest X-ray: left lower lobe infiltrates
Oxygen saturation 82% on room air
Labs: Na 145, K 4.1, Cl 100, CO2 26, Glu 160, BUN 23, sCr 1.3 WBCs 12.8, Hgb
10.2, Hct 31.1, Plts 310
- Which of the following is the most appropriate and complete list of efficacy
monitoring parameters for GH’s pneumonia?
A. Difficulty breathing, shortness of breath, breath sounds on the left side compared
with the right, rales in the left lower lobe, orientation/confusion, chest X-ray,
WBCs, temperature, respiratory rate
B. Difficulty breathing, shortness of breath, breath sounds on the left side compared
with the right, rales in the left lower lobe, orientation/confusion, chest X-ray,
WBCs, culture results
C. Difficulty breathing, shortness of breath, breath sounds on the left side compared
with the right, rales in the left lower lobe, orientation/confusion, chest X-ray,
WBCs, temperature, respiratory rate, creatinine clearance
D. Difficulty breathing, shortness of breath, breath sounds on the left side compared
with the right, rales in the left lower lobe, orientation/confusion, chest X-ray,
WBCs, creatinine clearance, culture results
A
GH is a 73-year-old woman presents to your ED on June 20th complaining of difficulty breathing and shortness of breath. Her physical examination reveals that she is confused and disoriented, has decreased breath sounds on the left side compared with the right, and has rales in the left lower lobe. Her temperature is 37.4C, respiratory rate is 30 breaths
per minute, and blood pressure is 90/65 mm Hg.
PMH Hypertension for 4 years, currently controlled
FH: Father died of lung cancer at the age of 68 years; mother died of natural causes.
SH: Smoked 1 pack per day for 5 years, quit 35 years ago. Does not drink alcohol.
She lives with her daughter.
Allergies: NKDA Height: 53 Weight: 165 pounds
Meds: Lisinopril 10 mg PO qd
ROS: (+) difficulty breathing and shortness of breath; (−) chest pain, N/V/D, weight
loss, change in appetite
PE: VS: BP 90/65, P 98, RR 30, T 37.4C
CV: RRR, normal S1, S2; no murmurs, rubs, or gallops
Lungs: Decreased breath sounds on the left side compared with the right and rales in the left lower lobe, breaths are shallow.
Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly, heme (−) stool
Neuro: Oriented to name and place but not to date. She is easily confused by
questions asked of her.
Diagnostic Tests
Chest X-ray: left lower lobe infiltrates
Oxygen saturation 82% on room air
Labs: Na 145, K 4.1, Cl 100, CO2 26, Glu 160, BUN 23, sCr 1.3 WBCs 12.8, Hgb
10.2, Hct 31.1, Plts 310
- GH was extubated after 24 hours and by 48 hours after admission was transferred from the medical intensive care unit to the internal medicine ward. Day 3 of hospitalization she is afebrile, and her WBCs are 8.6, oxygen saturation on room air 94% and she is fully oriented. The medical team would like to send her home; the most appropriate antibiotic therapy to send her home on is ____.
A. Ciprofloxacin 500 mg PO twice daily
B. Azithromycin 500 mg PO × 1 then 250 mg PO once daily
C. Amoxicillin-clavulanate 875/125 mg PO twice daily plus clarithromycin 500 mg
PO twice daily
D. Amoxicillin-clavulanate 875/125 mg PO twice daily plus levofloxacin 750 mg PO
once daily
C
GH is a 73-year-old woman presents to your ED on June 20th complaining of difficulty breathing and shortness of breath. Her physical examination reveals that she is confused and disoriented, has decreased breath sounds on the left side compared with the right, and has rales in the left lower lobe. Her temperature is 37.4C, respiratory rate is 30 breaths
per minute, and blood pressure is 90/65 mm Hg.
PMH Hypertension for 4 years, currently controlled
FH: Father died of lung cancer at the age of 68 years; mother died of natural causes.
SH: Smoked 1 pack per day for 5 years, quit 35 years ago. Does not drink alcohol.
She lives with her daughter.
Allergies: NKDA Height: 53 Weight: 165 pounds
Meds: Lisinopril 10 mg PO qd
ROS: (+) difficulty breathing and shortness of breath; (−) chest pain, N/V/D, weight
loss, change in appetite
PE: VS: BP 90/65, P 98, RR 30, T 37.4C
CV: RRR, normal S1, S2; no murmurs, rubs, or gallops
Lungs: Decreased breath sounds on the left side compared with the right and rales in the left lower lobe, breaths are shallow.
Abd: Soft, nontender, nondistended; (+) bowel sounds, no hepatosplenomegaly, heme (−) stool
Neuro: Oriented to name and place but not to date. She is easily confused by
questions asked of her.
Diagnostic Tests
Chest X-ray: left lower lobe infiltrates
Oxygen saturation 82% on room air
Labs: Na 145, K 4.1, Cl 100, CO2 26, Glu 160, BUN 23, sCr 1.3 WBCs 12.8, Hgb
10.2, Hct 31.1, Plts 310
- If GH had been in the hospital 2 months earlier for community-acquired pneumonia and received 4 days of ceftriaxone and azithromycin, would you recommend a different therapy for the current pneumonia?
A. No, the prior admission has no relevance to the current infection.
B. Yes, the regimen should be changed to cefepime and levofloxacin because these
are different drugs than what she was on before.
C. Yes, the regimen should be changed to include MDR GNB and MRSA coverage,
change ceftriaxone to cefepime, and add vancomycin.
D. Yes, the regimen should be changed to double cover Gram-negative bacilli, add
gentamicin.
C
