Gordon H. Sun, MD, MS

April 29, 2014

Case Challenge 4: An Older Patient With Comorbidities

A 63-year-old retiree presents to his internist with a 4-day history of low-grade fever, mild headache, and nonproductive cough. He had coronary angioplasty performed 5 years ago, and he currently takes metoprolol for atrial fibrillation and hydrochlorothiazide for hypertension. He has a 20-pack-year smoking history, and he drinks a 6-pack of beer every week. The patient has no known allergies.

On presentation, his temperature is 101.4°F (38.6°C), heart rate is regular at 88 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 130/85 mm Hg. The patient answers questions clearly and appropriately, and he shows no signs of airway distress. Head and neck examination is normal. He has no appreciable lymphadenopathy.

The patient demonstrates a frequent cough during the examination, and he experiences mild right-sided lower chest pain with each spasm of coughing. On chest examination, soft crackles can be heard on auscultation at the right lung base, as well as dullness to percussion in the same area. No murmurs or gallops are noted. Abdominal examination is normal.

Point-of-care blood tests demonstrated a white blood cell count of 18 cells/µL with neutrophilia; normal serum electrolytes, creatinine, and blood urea nitrogen; and a negative troponin test. Arterial blood gas analysis was within normal limits. Chest radiography demonstrated lobar consolidation in the right lower lobe. Electrocardiography demonstrated normal sinus rhythm. The patient was diagnosed with CAP.


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