Primary Care Case

In light of the primary care exam I have tomorrow morning... Here is a case study for others to suffer along with me...

A 66 year old M is brought in the office by his wife with complain of productive cough, fever, and chills for the past 2 days. The pt lives with his wife and is retired. PMH is significant for DM (for which he take insulin), CHF (ejection fraction of 40%), and has a hx of renal insufficiency. He is alert and oriented. There is no hx of smoking or ETOH abuse. On PE, he has crackles over his LL lung. Cardiovasc exam is normal.

Vital signs are:
BP 130/64
HR 128
RR 24
O2 sat on room air 97%

Chest xray shows infiltrates and consolidation in the LL lobe of the lung. Lab tests show WBC 15, hct 36, Na 142, glucose 167, BUN 36, Cr 1.5. What is the next step for this patient?

1 comment:

  1. Based on the information presented, the patient has SIRS + pneumonia= sepsis. Separately, according to CURB-65 rule, there is a 13% mortality in 6 months for this patient. I would consider inpatient treatment with ceftriaxone and azithromycin. I would also order sputum and blood cultures.