Pneumonia

Elevation of head - Pt presents w/ signs of aspiration pneumonia -A) RF for aspiration pneumonia include: ----1) Altered consciousness impairing cough reflex/glottic closure --------(dementia, drug intox) ----2) Dysphagia d/t neuro deficits --------(stroke, neurodegenerative disease) ----3) Upper GI tract disorders --------(GERD) ----4) Mechanical compromise os aspiration defenses --------(Nasogastric & endotracheal tubes) ----5) Protracted vomiting ----6) Large-volume tube feedings in recumbent position -B) Measures to PREVENT aspiration pneumonia include: ----1) Oral care ----2) Diet modification ----3) Elevation of head → to 30-45 degrees -C) MGMT ----a) TMT -------1) Clindamycin → broad spectrum antibiotics w/ good anaerobic coverage Frequent use of incentive spirometry - Would be used to reduce POST-OP PNEUMONIA ---(not used for aspiration pneumonia)

(UWS2E1) An 81M, is hospitalized 5 days ago for the acute onset of dense right-sided hemiparesis is found to be increasingly lethargic. Over the course of his hospitalization, the weakness in his right arm & leg has slightly improved & his speech has become more intelligible. he was recently started on a soft diet. The pts other medical problems include HTN, hypercholesterolemia, & psoriasis. Temp is 102F, BP is 100/60, & pulse is 120/min. On chest auscultation, coarse rhonchi are heard over the right lung. Heart sounds are normal. Abd is soft & non-tender. Extremities have no cyanosis/edema. Leukocyte Ct is 18,5K, Hb is 9.8, & PLTS Ct is 490K. A CXR reveals an infiltrate in the posterior segment of the right upper lobe. Which of the following would have most likely have prevented this pts current condition? (Elevation of head VS Frequent use of incentive spirometry VS Nasogastric tube feeding)

Voriconazole - Pt presents w/ pneumonia - MGMT of pneumonia is focused on the most likely organism & CURB-65 - Galactomannan antigen is specific for aspergillosis -A) MGMT ---1) "AZOLE" → FIRST CHOICE TMT for a fungal infection Incorrect: Piperacillin-Tazobactam - Used for Pts w/ pneumonia suspected to be caused by pseudomonas - Pseudomonas is suspected in pts that are immunocompromised - However, key differences are: ---1) Galactomannan antigen would not be positive for pseudomonas -------(Specific for aspergillosis)

3) A 69-year-old man with metastatic colon cancer is brought to the emergency department because of shortness of breath, fever, chills, and a productive cough with streaks of blood for the past 5 days. He has a history of emphysema. The patient does not have abdominal pain or headache. He receives chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin every 6 weeks; his last cycle was 3 weeks ago. His temperature is 38.3°C (101°F), pulse is 112/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 83%. A few scattered inspiratory crackles are heard over the right lung. His mucous membranes are dry. Cardiac examination is normal. Laboratory studies show: - Hb-------------------------------9.3 - Leukocytes----------------------700 - Neutros--------------------------68% - Lymphos-------------------------25% - Eosinos--------------------------4% - Monocytes----------------------3% - PLTS------------------------------104 - Glucose--------------------------75 - BUN------------------------------41 - CR--------------------------------2.1 - Galactomannan Ag-------------Pos Which of the following is the best initial pharmacology? (Voriconazole VS Piperacillin-Tazobactam)

Outpatient w/ oral Doxy - Pt has a CURB-65 score of zero, criteria include: ---C → Confusion ---U → BUN > 20 ---R → RR > 30 ---B → BP; systolic <90, Diastolic <60 ---65 → age ≥ 65 -A) MGMT for CAP includes: ---1) AZ/Doxy monotherapy → First line for pts w/: ---------a) no antibiotic use for 3 months -------------(pt used antibiotics 4 months ago) ----------b) no underlying/chronic diseases) Outpatient w/ levofloxacin -TMT for pts w/ CAP AND -----a) Antibiotic use ≤ 3 months -----b) Underlying chronic conditions → (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism -A) MGMT ----1) Flouroquinoline (moxifloxacin, levofloxacin, gemifloxacin) OR ----1) β-lactam (first-line agents: high-dose amoxicillin, amoxicillin-clavulanate; ---------alternative agents → (ceftriaxone, cefpodoxime, or cefuroxime) ----2) PLUS a macrolide (azithromycin, clarithromycin, or erythromycin).

A 36-year-old woman comes to the physician because of a 4-day history of fever, malaise, chills, and a cough productive of moderate amounts of yellow-colored sputum. Over the past 2 days, she has also had right-sided chest pain that is exacerbated by deep inspiration. Four months ago, she was diagnosed with a urinary tract infection and was treated with trimethoprim/sulfamethoxazole. She appears pale. Her temperature is 38.8°C (101.8°F), pulse is 92/min, respirations are 20/min, and blood pressure is 128/74 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Examination shows pale conjunctivae. Crackles are heard at the right lung base. Cardiac examination shows no abnormalities. Laboratory studies show: - Hb-------------------------------12.6 - Leukocytes----------------------13,3K - PLTS------------------------------230 - Na+-------------------------------137 - Cl---------------------------------104 - K+---------------------------------3.9 - BUN-------------------------------19 - Glucose---------------------------89 - Cr---------------------------------0.8 An x-ray of the chest shows an infiltrate at the right lung base. Which of the following is the most appropriate next step in management? (Outpatient w/ oral Doxy VS Outpatient w/ levofloxacin)

Ampicillin-Sulbactum - Pt presents w/a lung abscess -A) MGMT ---1) Ampicillin-Sulbactum → PREFERRED FOR ABSCESS -------(for 72-96 hours) ---2) Carbapenem ---3) Clindamycin ------(If penicillin allergy) Vancomycin & levofloxacin - Used in community acquired pneumonia - However, not effective in Aspiration pneumonia i.e.m, lung abscesses) which are generally composed of POLYMICROBIAL organisms Metronidazole - Not effective for lung abscess b/c lung abscess may contain microaerophilic organisms

A 40-year-old man comes to the physician because of a 6-week history of increasing shortness of breath, fatigue, and fever. He has had a cough productive of foul-smelling sputum for 4 weeks. He was hospitalized for alcohol intoxication twice over the past 6 months. He has hypertension and depression. He has smoked one pack of cigarettes daily for 20 years and drinks 6 alcoholic beverages daily. Current medications include ramipril and fluoxetine. He appears malnourished. He is 185 cm (6 ft 1 in) tall and weighs 65.7 kg (145 lb); BMI is 19.1 kg/m2. His temperature is 38.3°C (100.9°F), pulse is 118/min, respirations are 24/min, and blood pressure is 147/96 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. Examination of the chest shows dullness to percussion over the right upper lung field. An x-ray of the chest shows a lung cavity with an air-fluid level and surrounding infiltrate in the right upper lobe of the lung. Which of the following is the most appropriate next step in management? (Ampicillin-Sulbactum VS Metronidazole VS Vanco & levofloxacin)

Supportive TMT only - Pt presents w/ acute bronchitis (viral infection) -A) Signs/Symptoms ---1) Cough + mild dyspnea on exertion → 5 days after URI symptoms ---2) It is the ABSENCE OF CERTAIN SYMPTOMS that help us to determine it is a VIRAL infection, including -----a) ABSENCE of green-yellow sputum ----------[Pt Productive cough w/ whitish non-bloody sputum] -----b) NO lung consolidation ----------(lung consolidaient is seen in pneumonia) -----c) NO fever ----------(Bacterial Pneumonia usually presents w/ fever) -B) MGMT ---1) Supportive TMT ------(Pt has signs of a VIRAL infection) Administer amoxicillin-Clavulanate - Would be administered if pt was suspected to have a bacterial infection -However, bacterial infections present w/ key characteristics including: ---1) YELLOW-GREEN sputum ---2) High fever ---3) Lung consolidation

A 40-year-old woman comes to the physician with a 5-day history of mild shortness of breath with exertion. She has also had a cough for 5 days that became productive of whitish non-bloody sputum 3 days ago. Initially, she had a runny nose, mild headaches, and diffuse muscle aches. She has not had fevers or chills. Three weeks ago, her 9-year-old son had a febrile illness with a cough and an exanthematous rash that resolved without treatment 1 week later. The patient has occasional migraine headaches. Her sister was diagnosed with antiphospholipid syndrome 12 years ago. The patient does not smoke; she drinks 3-4 glasses of wine per week. Her current medications include zolmitriptan as needed. Her temperature is 37.1°C (99°F), pulse is 84/min, respirations are 17/min, and blood pressure is 135/82 mm Hg. Scattered wheezes are heard at both lung bases. There are no rales. Egophony is negative. Which of the following is the most appropriate next step in management? (Administer amoxicillin-Clavulanate VS Supportive TMT only)

E -Pt most likely presents w/ a severe asthma attack/exacerbation -A) Signs/Symptoms ---1) Anxious, progressive SOB & chest tightness for 3 hours ---2) Tachycardia -B) RF ---1) Smoking for 15 years ---2) Non-productive cough for past 2 months -C) Chest x-ray findings show pulmonary inflation → which supports long-term asthma in pt ---1) parenchymal lucency, ---2) a low, flattened diaphragm, ---3) wide intercostal spaces -D) Expected findings include: ---1) Chest excursion → SYMMETRIC ------(Asthma pts usually have equal & bilateral effects on the lungs) ---2) Breath sounds → DECREASED ------(Asthma presents w/ AIR-TRAPPING) ---3) Chest percussion → HYPER-RESONANT ------(D/t AIR-TRAPPING) ---4) Tactile fremitus → DECREASED ------(B/c of air trapping) Alternative choice (C) - This would be expected in pulmonary fibrosis - Although this pt has a RF for pulmonary fibrosis (FARMER) → pulmonary fibrosis typically presents as a CHRONIC/INDOLENT disease ---[Pt has had symptoms for 3 hours w/ intermittent cough for 2 months] ---1) Chest excursion → symmetric ---2) Breath sounds → BASAL CRACKLES ---3) Chest percussion → DULL ---4) Tactile fremitus → INCREASED - This would be expected in pulmonary fibrosis

A 42-year-old woman comes to the emergency department because of progressive shortness of breath and chest tightness for 3 hours. She has had an intermittent non-productive cough for the past two months. Her 16-year old son had an upper respiratory infection last week and was treated with azithromycin. She has smoked a pack of cigarettes daily for 15 years but stopped smoking 5 years ago. She works at a cattle ranch. Her temperature is 37.5°C (99.5 F), pulse is 100/min, her blood pressure is 130/70 mmHg, and respirations are 28/min. She appears anxious and is unable to speak in full sentences. A chest x-ray is shown. Further evaluation of this patient is most likely to show which of the following sets of findings?

Influenza vaccine - Vaccination of patients who have not received the influenza vaccine during the flu season is recommended by the CDC, ACIP, and WHO at least 2 weeks prior to travel Low-Dose CT scan of chest - although the pt has a 20 year smoking Hx → he does not meet the criteria for Low-Dose CT - Criteria for Low-dose CT of the chest includes: ---1) Individuals 55-80 years of age → who have at least a 30 pack-year smoking history -----[pt has a 20 year smoking Hx]

A 62-year-old man comes to the physician in May for a routine health maintenance examination. He feels well. He underwent a right inguinal hernia repair 6 months ago. He has hypertension and type 2 diabetes mellitus. There is no family history of serious illness. Current medications include metformin, sitagliptin, enalapril, and metoprolol. He received the zoster vaccine 1 year ago. He received the PPSV23 vaccine 4 years ago. His last colonoscopy was 7 years ago and was normal. He smoked a pack of cigarettes a day for 20 years but quit 17 years ago. He drinks two to three alcoholic beverages on weekends. He is allergic to amoxicillin. He is scheduled to visit Australia and New Zealand in 2 weeks to celebrate his 25th wedding anniversary. He appears healthy. Vital signs are within normal limits. An S4 is heard at the apex. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate recommendation at this time? (Influenza vaccine VS Low-Dose CT scan of chest)

Increase the A-a gradient -A) Pathophysio of pneumonia ---1) In pneumonia, there is decreased ventilation of the consolidated portion of the lung due to alveolar inflammation (↓ V). ---2) In a lateral decubitus position, the dependent lung is better perfused (↑ Q). ---3) Putting this patient in the left lateral decubitus position results in increased perfusion of the non-ventilated alveoli → resulting in a V/Q mismatch, and an increase in the A-a gradient Improve the hypoxemia -The perfusion of the non-ventilated, consolidated alveoli in pneumonia causes a decreased V/Q ratio that results in hypoxemia -Placing the patient in the left decubitus position would actually worsen hypoxemia → as more blood passes through the non-ventilated portion of the lung and less passes through the right (healthy) lung

A 62-year-old man is brought to the emergency department with a 2-day history of cough productive of yellowish sputum. He has had fever, chills, and worsening shortness of breath over this time. He has a 10-year history of hypertension and hyperlipidemia. He does not drink alcohol or smoke cigarettes. His current medications include atorvastatin, amlodipine, and metoprolol. His temperature is 38.9°C (102.0°F), pulse is 105/min, respirations are 27/min, and blood pressure is 110/70 mm Hg. He appears in mild distress. He has rales over the left lower lung field. The remainder of the examination shows no abnormalities. Leukocyte count is 15,000/mm3 (87% segmented neutrophils). Arterial blood gas analysis on room air shows: - pH-------------------------------7.44 - PO2------------------------------68 - PCO2-----------------------------28 - HCO3----------------------------24 - O2 sat----------------------------91% An x-ray of the chest shows a consolidation in the left lower lobe. Asking the patient to lie down in the left lateral decubitus position would most likely result in which of the following? (Improve the hypoxemia VS Increase the A-a gradient)

In-patient w/ AZ & cefotaxime - Pt has CAP & Meets the CURB-65 IN-PATIENT criteria -A) MGMT IN-PATIENT pneumonia includes ---1) TMT → Combination of -------a) Macrolide (AZ) -------b) Anti-pneumococcal beta-lactam (Cefotaxime) ------c) +/- fluoroquinolone (levofloxacin) In-patient w/ AZ, Cefepime, gentamicin - This is used to for Pseudomonas suspected pneumonia -A) Criteria to suspect Pseudomonas includes: ----1) Immunosuppression ----2) Long Hospital stay ----3) Ventilation >3 days ----4) Structural lung disease -------[pt does not meet criteria]

A 67-year-old woman is brought to the emergency department for the evaluation of fever, chest pain, and a cough productive of a moderate amount of greenish-yellow sputum for 2 days. During this period, she has had severe malaise, chills, and difficulty breathing. She has hypertension, hypercholesterolemia, and type 2 diabetes mellitus. She smoked one pack of cigarettes daily for 20 years, but quit 5 years ago. Current medications include simvastatin, captopril, and metformin. Temperature is 39°C (102.2°F), pulse is 110/min, respirations are 33/min, and blood pressure is 143/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 94%. Crackles are heard on auscultation of the right upper lobe. Laboratory studies show a leukocyte count of 12,300/mm3, an erythrocyte sedimentation rate of 60 mm/h, and a urea nitrogen of 15 mg/dL. A chest x-ray is shown. Which of the following is the most appropriate next step in the management of this patient? (In-patient w/ cefepime, AZ, & gentamicin VS In-patient w/ AZ & Cefotaxime)

Levofloxacin & Cefepime - Pt has a CURB-65 of 3 ---1) respiratory rate ≥ 30/min, ---2) systolic blood pressure ≤ 90 mm Hg, ---3) age ≥ 65 years) -A) CURB-65 interpretation ----CURB-65 score of 2 = hospitalization ------(Pt should be hospitalized) Additionally, the pt needs meds -A) MGMT ---TMT for pts w/ CAP & SUSPECTED PSEUDOMONAS INFECTION ----a) Criteria to suspect pseudomonas includes: -------1) History of prior antibiotic treatments, -------2) COPD, -------3) possible immunosuppression due to chemotherapy, -------4) greenish sputum, -------5) gram-negative rods on Gram stain -B) MEDS ----1) Cefepime and levofloxacin → first-line treatment in pts w/ suspected pseudomonas infection ---2) Other treatment options for CAP with P. aeruginosa include ------a) Piperacillin/tazobactam, meropenem, or imipenem PLUS a fluoroquinolone -------b) ± aminoglycoside Ertapenem - Ineffective against pseudomonas Ceftriaxone & AZ - Combination therapy with ceftriaxone & azithromycin is used to treat severe CAP that requires admission to the ICU (e.g., acute respiratory failure, septic shock) - However, there is a HIGH LIKELIHOOD that this pt has an infection from pseudomonas - Ceftriaxone & AZ are INEFFECTIVE against pseudomonas

A 68-year-old man comes to the emergency department because of a cough, dyspnea, and fever for 1 day. The cough is productive of small amounts of green phlegm. He has metastatic colon cancer and has received three cycles of chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin; his last chemotherapy session was 2.5 months ago. He has chronic obstructive pulmonary disease and has been treated with antibiotics and prednisolone for acute exacerbations three times in the past year. His medications include a fluticasone-salmeterol inhaler and a tiotropium bromide inhaler. He has smoked one pack of cigarettes daily for 48 years. His temperature is 39.1°C (103.1°F), pulse is 112/min, respirations are 32/min, and blood pressure is 88/69 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Pulmonary examination shows diffuse crackles and rhonchi. An x-ray of the chest shows a left upper-lobe infiltrate of the lung. Two sets of blood cultures are obtained. Endotracheal aspirate Gram stain shows gram-negative rods. Two large bore cannulas are inserted and intravenous fluids are administered. Which of the following is the most appropriate pharmacotherapy? (Ertapenem VS Ceftriaxone & AZ VS Levofloxacin & Cefepime)

Discontinue Ceftriaxone & AZ - This patient has classic findings of a viral lower respiratory infection, including: A) Signs/Symptoms ---1) Fever, ---2) Myalgia, ---3) cough, ---4) bilateral reticulonodular opacities, ---5) a consistently low (PCT) procalcitonin level -------PCT is produced by cells as a response to bacterial toxins -------Results in ELEVATED LEVELS during bacterial infections -------Low PCT levels < 0.25 μg/L suggest a viral etiology & can be used to support the decision to stop empiric antibiotics for suspected bacterial pneumonia

A 72-year-old woman is brought to the emergency department with fever, myalgia, and cough for 3 days. She lives in an assisted living facility and several of her neighbors have had similar symptoms. She has hypertension treated with lisinopril. She has not been vaccinated against influenza. Her temperature is 38.9°C (102.2°F), pulse is 105/min, respirations are 22/min, and blood pressure is 112/62 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 89%. Her leukocyte count is 10,500/mm3, serum creatinine is 0.9 mg/dL, and serum procalcitonin level is 0.05 μg/L (N < 0.06). An x-ray of the chest shows reticulonodular opacities in the lower lobes bilaterally. Blood and sputum cultures are negative. The patient is admitted to the hospital and empirical treatment with ceftriaxone and azithromycin is begun. Two days after admission, her temperature is 37.6°C (99.7°F) and pulse oximetry shows an oxygen saturation of 96% on room air. Her serum procalcitonin level is 0.04 μg/L. Which of the following is the most appropriate next step in management? Continue ceftriaxone & AZ to complete 7-day course VS Discontinue ceftriaxone & AZ)

RSV - Pt presents w/ Bronchiolitis -A) RF ---1) An previous URI ------(low-grade fever, stuffy nose) ---2) Child <2 years of age -B) Signs/symptoms → followed by: ---1) a cough ---2) signs of respiratory distress --------(tachypnea, nasal flaring, intercostal retractions, oxygen saturation of 92%) with expiratory wheezes S.agalactiae, Ecoli, Listeria - Usually the cause of ---a) sepsis, pneumonia, sometimes meningitis - Neonatal pneumonia can present w/ many of the symptoms this Infant is currently having, including: apnea, lethargy, fever, poor feeding, coughing, tachypnea, respiratory distress, and circulatory distress - However, key differences are: ----1) Presents within 24 hours after birth but may occur up to day 6 of life → most commonly between weeks 4 and 5 of life and usually present as bacteremia or meningitis -------(pt his already passed this point at 6 WEEKS old) ---2) pneumonia DOES NOT PRESENT w/Expiratory wheezes ------[Pt which would have CRACKLES if he had pneumonia]

A previously healthy 6-week-old infant is brought to the emergency department because of fever, fatigue, and dry cough for one day. She has been feeding poorly and had difficulty latching on to breastfeed since yesterday. She has had nasal congestion. The mother reports that her daughter has not been going through as many diapers as usual. She was born by uncomplicated vaginal delivery at 42 weeks' gestation. Her mother is a cystic fibrosis carrier. The patient has been treated with acetaminophen for the last 24 hours, and vitamin D drops since birth. She appears irritable, pale, and lethargic. She is at the 25th percentile for both length and weight; she had the same percentiles at birth. Her temperature is 38.2°C (100.7°F) and respirations are 64/min. Pulse oximetry on room air shows an oxygen saturation of 92%. Examination shows an ill-appearing infant with a cough and nasal flaring. Mucous membranes are dry. Chest examination shows intercostal and supraclavicular retractions. Expiratory wheezes are heard on auscultation. Which of the following is the most likely causal organism? (S.agalactiae VS E.coli VS Listeria VS RSV)

Gm(+) diplococci -S. pneumo is the most COMMON cause of CAP in NURSING HOME RESIDENTS Gm(-) coccobacilli - Could indicate ---1) Enterobacteriaceae such as E. coli, ---2) Klebsiella pneumoniae, ---3) Pseudomonas aeruginosa, - which can also cause typical pneumonia - However, the key to determining which organism is MOST LIKELY is based on RF, including: ---1) Pneumonia due to E. coli is mainly found in neonates or patients with aspiration pneumonia ---2) P.aeruginosa may cause: -------a) ventilator-associated pneumonia -------b) is especially common in patients with cystic fibrosis ---3) K. pneumonia is commonly responsible for nosocomial infections in immunocompromised patients

An 80-year-old man is brought to the emergency department from a nursing home because of a 2-day history of increasing cough, fever, and dyspnea. He has type 2 diabetes mellitus and hypertension. Current medications include insulin and enalapril. On arrival, he has dyspnea and is disoriented to time, place, and person. His temperature is 38.1°C (100.6°F), pulse is 113/min, respirations are 35/min, and blood pressure is 78/60 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 77%. Auscultation shows diffuse crackles over the right lung field. Cardiac examination shows an S4 gallop. Intravenous fluid resuscitation is begun. He is intubated, mechanically ventilated, and moved to the intensive care unit. An x-ray of the chest shows right upper and middle lobe infiltrates and an enlarged cardiac silhouette. A norepinephrine infusion is begun and the patient is administered intravenous antibiotics. Despite appropriate therapy, he dies the following day. Which of the following would most likely be found on Gram stain examination of this patient's sputum? (Gm(+) diplococci VS Gm(-) coccobacilli)

All-trans retinoic acid -A) MGMT of AML (M3) includes: ----1) Chemotherapy ----2) All-trans retinoic acid -------a) Specific TMT for acute promyelocytic leukemia ----3) PLTS transfusions -------a) To prevent DIC in AML (M3) -----4) Red blood cell transfusions -----5) Antibiotics ---------a) for febrile patients -----6) Uric acid lowering agents Amoxicillin - Pt presents w/ pneumonia - However, Pt should be hospitalized based on her presentation, including (Acute presentation, higher fever, RR of 30/min, & underlying condition - AML) - Even if pt was treated as an outpatient for pneumonia, first line TMT of pneumonia is AZ/Doxy -----[NOT Amoxicillin]

TRUE LEARN A 22-year-old woman presents to the Emergency Department with dyspnea and fever for the past 24 hours. The symptoms developed fairly suddenly with fevers, chills and rigors in addition to productive cough. She also complains of frequent, intermittent nose bleeds and easy bruising for the past month. Her temperature is 39.3°C (102.7°F), pulse is 108/minute and regular, respirations are 30/minute, and blood pressure is 113/74 mmHg. Oxygen saturation is 92% on room air. There are rales over the right mid lung field. A chest x-ray shows a right middle lobe pneumonia with possible necrotizing changes. Laboratory results are below: - Leukocytes------------------------------1,1K - Hb---------------------------------------8.1 - PLTS-------------------------------------45K - PT time----------------------------------20 sec - aPTT-------------------------------------54 sec - INR---------------------------------------3.4 Fibrin split products Elevated A peripheral smear is highly suggestive of acute promyelocytic leukemia; cytogenetic studies are pending. Which of the following is the most appropriate initial treatment? All-trans retinoic acid VS Amoxicillin)

Pneumonia -A) RF ---1) Common Post-op complication ------(usually seen 3-5 days post-op) ---2) Smoking Hx -B Signs/Symptoms Key symptoms ---1) Fever, crackles ---2) Can present w/ pleuritic chest pain ---3) Cough -C) CXR ---1) lower lung consolidation --------(KEY DIFFERENTIATING SYMPTOM to differentiate from Pulmonary embolism) Incorrect: Pulmonary embolism - Also Presents w/ pleuritic chest pain, cough, hypotension, & A RF for developing PE immobility is immobility (recent surgery) - However, key differences are: ---1) Pt would most likely have a PMHx sig for DVT/Tachycardia ---2) Pt Fever, cough, crackles ---3) Dyspnea, Cough, ---4) Crackles -------(However, the crackles would not be localized) ---5) tachycardia, ---6) obstructive shock

Three days after undergoing an open cholecystectomy, an obese 57-year-old woman has fever, chills, and a headache. She has right-sided chest pain that increases on inspiration and has had a productive cough for the last 12 hours. She had an episode of hypotension after the operation that resolved with intravenous fluid therapy. She underwent an abdominal hysterectomy 16 years ago for multiple fibroids of the uterus. She has smoked one pack of cigarettes daily for 17 years. She appears uncomfortable. Her temperature is 39°C (102.2°F), pulse is 98/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Inspiratory crackles are heard at the right lung base. The abdomen is soft and nontender. There is a healing surgical incision below the right ribcage. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis? (Pneumonia VS Pulmonary embolism)

Strep -A) Etiology ---1) MOST COMMON CAUSE of post-influenza viral infection ---2) Can present w/ UPPER LOBE consolidation Staph - Can also present as a post-influenza superinfection and should be suspected if patients present with bacterial pneumonia symptoms within 2-3 days of onset of viral symptoms Additionally, S. aureus should be suspected if patients are: ---1) severely ill on presentation (e.g., hypoxemia, high fever, elevated WBCs) ---2) Have multiple cavitary lesions on chest x-ray. - However, key differences in presentation are: ---1) Staph presentation is MORE SEVERE, including -------a) A MORE RAPID course of illness -----------[pt has been sick for almost 2 weeks] -------b) MORE SEVERE symptoms -----------[pt is described as having general malaise & a moderately productive cough]

Twelve hours after admission to the hospital because of a high-grade fever for 3 days, a 15-year-old boy has shortness of breath. During this period, he has had generalized malaise and a cough productive of moderate amounts of green sputum. For the past 10 days, he has had fever, a sore throat, and generalized aches; these symptoms initially improved, but worsened again over the past 5 days. His temperature is 38.7°C (101.7°F), pulse is 109/min, respirations are 27/min, and blood pressure is 100/70 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 93%. There are decreased breath sounds and crackles heard over the upper right lung field. His hemoglobin concentration is 13.3 g/dL, leukocyte count is 15,000/mm3, and platelet count is 289,000/mm3. An x-ray of the chest shows a right upper-lobe infiltrate. Which of the following is the most likely cause of this patient's symptoms? (Staph VS Strep)