Infectious Disease Case Study

Infectious Disease Case Study

Infectious Disease Case Study

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Infectious Disease Case Study

CC: L.F. is a 20 year old male college student with a 2-week history of

cough and increased sputum production who presents to your clinic with new chest

pain when he coughs, shortness of breath, intermittent fever and chills and

blood-tinged sputum.

HPI: Cough treated with guiafenesin with dextromethorphan obtained form

roommate

Allergies: sulfa (nausea)

Physical examination:

GEN: DOE and pleuritic chest pain

VS: BP

120/75 HR 95 T 100.5 RR 35 WT 90kg HT 6’4″

CHEST: LUL is CTA with

significantly decreased breath sounds. There are E-to-A changes in the LLL and

across the middle of the right lung field.

COR: tachycardic, no

MRG

HENT: WNL

ABD: WNL

GU: WNL

NEURO: WNL

SKIN: WNL

Chest X-ray: Consolidation of the inferior segments of the LLL. Remainder of

the lungs are clear. Heart size WNL.

Sputum Gram Stain: many WBC, few epithelial cells, moderate gram-positive

cocci in chains and pairs

Questions to Answer:

Based upon what you learned in class and from your readings, what are the 2
most likely pathogens that would cause pneumonia in this patient?

Based upon your answer to the above question, and the gram stain, what is
the most likely causative microorganism in this patient?

What would you prescribe for this patient to treat his infection, and what
would you tell this patient about those medications (i.e. AE, monitoring of

condition…)?

What other medications would you prescribe for this patient?
How would you follow-up with this patient (i.e. under what circumstances
would you see him back)?

 

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