Correct answer for yesterdays USMLE-style question is A! See explanation below. Any questions? Ask and well answer! A) This patient is likely suffering from community acquired pneumonia (CAP). She has a productive cough, a fever, respiratory difficulties and a physical exam suggestive of a consolidation. It is likely this patient had pneumonia at her first visit to the Emergency Department. In non-complicated cases of CAP, outpatient treatment with a macrolide is appropriate. However, in many places there is growing resistance of Streptococcus pneumonia to macrolide antibiotics. The CURB-65 criteria is a tool used by clinicians to determine how to manage patients with CAP. Patients are given 1 point for each of the following: - Confusion (compared to baseline) - BUN greater than 20 mg/dL - Respiratory rate greater than 30/min - Systolic blood pressure less than 90 mm Hg or diastolic blood pressure less than 60 mm Hg - Age 65 or older The points are totaled, with the following recommendations: - 1-2 points: consider hospital admission - 3 points: admit to the hospital - 4-5 points: consider ICU admission This patient’s CURB-65 score is 3: elevated BUN, elevated respiratory rate, and age over 65. Therefore, the best initial management is to admit her to the hospital and begin antibiotic therapy. Since this patient recently received antibiotic therapy, she is at risk for having a drug-resistant organism, so her therapy should be changed. In patients that have recently received a macrolide, a respiratory fluoroquinolone such as ciprofloxacin is appropriate therapy until a specific organism and drug sensitivity is determined. Incorrect answers: B) This patient needs to be admitted to the hospital. Hospitalized patients with CAP should be treated with either a respiratory fluoroquinolone or a β-lactam plus a macrolide. Since this patient was recently treated with azithromycin an antibiotic from another drug class should be used to replace the macrolide such as a respiratory fluoroquinolone or doxycycline. C) Based on this patient’s CURB-65 score, ICU admission is not warranted at this time. If on top of her current situation she also had significantly lower blood pressure or confusion, then ICU admission should be considered. D, E, F) Outpatient treatment of this woman would be inappropriate. She is clearly in respiratory distress with a respiratory rate of 32 and an oxygen saturation level at 92%. Coupled with her elevated BUN and her age, she should be admitted and treated in the hospital. Note that doxycycline or levofloxacin would be appropriate therapies in this patient if she were well enough to be treated in an outpatient setting.
Posted on: Fri, 16 May 2014 16:01:21 +0000
Trending Topics
Recently Viewed Topics
© 2015