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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of mild and moderate-to-severe pneumonia

  • Identify the goals of therapy for pneumonia

  • Develop an appropriate empiric treatment and monitoring plan for pneumonia on the basis of individual patient characteristics

  • Properly educate patients taking their antibiotic therapy

  • Discuss the role of vaccination in pneumonia

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PATIENT PRESENTATION

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Chief Complaint

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"For the last 2 days I have been more and more short of breath, even occurring at rest. I have also been coughing and the color of the secretions is now green."

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History of Present Illness

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Cindy Milner is a 65-year-old woman who presents to the emergency department complaining of increasing SOB and increasing coughing. She has had a fever for the last 24 hours. She has some mild-to-moderate chest discomfort, but denies any sharp pains or heaviness in her chest.

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Past Medical History

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COPD × 15 years

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DM × 20 years

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HTN × 10 years

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Family History

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Father died in a car accident at age 50. Mother had diabetes, HTN, and CRF, and died at age 56. She has 1 sister who has diabetes and HTN.

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Social History

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She lives with her husband and has no children. She works as a legal secretary.

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Tobacco/Alcohol/Substance Use

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Social drinker; + tobacco history 1 ppd × 30 years, quit 5 years ago, no illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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Penicillin

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Sulfamethoxazole

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Medications (Current)

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Lisinopril 20 mg PO daily

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Insulin glargine 40 units subcutaneous daily

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Insulin aspart subcutaneous sliding scale

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Fluticasone/salmeterol DPI 250 mcg/50 mcg 1 inhalation twice daily

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Albuterol 1–2 puffs every 4–6 hours as needed for SOB

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Acetaminophen 500 mg PO as needed for headache

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Review of Systems

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Occasional headaches relieved with acetaminophen; occasional tinnitus; (−) vertigo; (−) history of seizures, syncope, or loss of consciousness; mild pain/discomfort in her chest/abdomen; SOB; (−) nausea, vomiting, or diarrhea.

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Physical Examination

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General
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Breathing fast, with increased work of breathing, appears in moderate-to severe respiratory distress

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Vital Signs
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BP 88/58 mm Hg, P 100, RR 30, T 38.8°C, pulse oximetry 89% (0.89) on room air

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Weight 223 lb (101.4 kg)

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Height 65 in. (165 cm)

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Skin
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Normal; (−) rashes or lesions

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HEENT
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PERRLA, EOMI; trace periorbital edema; (−) ...

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