CASE NO. 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 with streaks of blood. 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. The patient 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. The patient is a retired truck driver who has been treated for mild hypertension, bronchitis, appendicitis (as a young adult), hemorrhoids and a fractured femur and splenic injury (motorcycle accident).

PHYSICAL EXAMINATION: The patient is an elderly man who appears tired haggard and underweight. His complexion is sallow. 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, apical heart rate 112/minute and regular, respiratory rate 24/minute and somewhat labored, temperature 102.6^oF. Examination of the neck reveals a large, non-tender hard lymph node in the right supraclavicular fossa. Both lungs are resonant by percussion with one exception: the right mid-anterior and right mid-lateral lung fields are dull. Auscultation reveals bilateral diminished vesicular breath sounds. Bronchial breath sounds, rhonchi and late inspiratory crackles (are heard) in the area of the right mid-anterior and right mid-lateral lung fields. The remainder of the lung fields is clear. Percussion and auscultation of the heart reveals no significant abnormality. Examination of the fingers shows clubbing.

LABORATORY: WBC 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.

COURSE OF ILLNESS: Following a chest x-ray PA view and Lateral which revealed an acute pneumonia in the right middle lobe, the patient was treated with antibiotics as an outpatient. During the 10 days of treatment the patient's fever abated and he felt somewhat better. A post-treatment (follow up) chest x-ray reveals a right hilar mass. Sputum cytology demonstrates atypical cells.

1.Identify the problems from the history.

2. Identify and explain the significance of physical findings.

3. Review the lab findings. What is your diagnosis?

4. What do you understand by the terms "hospital acquired" and "community acquired " pneumonia.? Which type of pneumonia does our patient have?

5. What organisms are likely to be causing his pneumonia?

6. List the various host factors, or conditions which predispose a patient to developing pneumonia. What host factors may have predisposed this patient to pneumonia?

7. Explain the pathogenesis of pneumococcal pneumonia? What virulence factors are important? What pathologic changes are produced in the lungs because of pneumonia?

8. How is the specific diagnosis established? What is the primary disadvantage to the examination of expectorated sputum? Describe characteristic morphology/growth of S. pneumoniae.

9. What antimicrobial agents would you prescribe for this patient? Would you use or avoid penicillin, and why? What is the duration of treatment?

10. What is the mechanism of pneumococcal resistance to penicillin?

11. What are the complications of Pneumococcal pneumonia?

12. Is prevention possible?

CASE NO. 2

A 15 year old female with a history of hay fever develops fever, headache and malaise for 4 days followed by a nonproductive cough and scratchy throat. Despite chicken soup and orange juice, the cough and fever persist, and her mother drags her to your office. On examination, her temperature is 101^o, pulse 90 beats/min, BP 110/70, respiratory rate 20 beats/min Physical examination is unremarkable except for scattered rales over the left lower lung, and small bullae in her left tympanic membrane. Chest x-ray reveals a patchy left lower lobe infiltrate. At your request, she makes a heroic effort but is unable to produce sputum

1. What is the  type of pneumonia this patient is likely to have? 

2. What is "atypical pneumonia"?

3. What is the differential diagnosis of atypical pneumonia?

4. What is the most likely organism in this patient and why?

5. Describe Mycoplasma pneumoniae.

6. What is the pathogenesis of infection produced by these agents? What pathologic changes are produced in the lungs?

7. How does immunity to Mycoplasma pneumonias develop ? Is reinfection possible?

8. How is the diagnosis established in atypical pneumonia?

9. What antimicrobial agent(s) would you use ?

10. You start the patient on Erythromycin. If he is taking antihistamines, what drug interaction might occur?

CASE NO. 3

A 35 year alcoholic male with a history of seizures is admitted with a three week history of fever, generalized weakness, poor appetite, and cough productive of green, foul - smelling sputum. On physical examination, the temperature is 100.3 degrees P. pulse is 96 beats per minute, respiratory rate is 20 breaths per minute, and BP is 120/80 mm. There are many missing teeth with gingivitis and dental caries. He has rales and decreased breath sounds over the right base. Chest x-ray shows consolidation in the superior segment of the right lower lobe. 

1. What type of infection is suggested by his foul smelling sputum?

2. What organisms could be responsible for this patient's pneumonia?

3. Does a normal person aspirate?

4. What then determines who gets infection?

5.  What are the other predisposing factors for aspiration? What factor/s predisposed this patient to aspirate?

6. Describe the pathogenesis of this pneumonia.

7. What are the common sites for aspiration lung abscess and why ?

8. What is the normal clinical picture of lung abscess? Does this patient fit that clinical picture?

9. Are there other routes besides aspiration by which anaerobes can reach lungs?

10. What complications are associated with this infection?

11. How would you treat this patient?

12. What organisms might be the cause of a hospital acquired aspiration pneumonia?