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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