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Internal Medicine

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A 28-year-old woman is hospitalized with a 5-day history of chest pain, fever, and cough with green sputum. Two weeks ago, she developed an influenza-like illness and seemed to improve before the onset of the most recent symptoms. She has no other medical conditions and takes no medications.

On physical examination, temperature is 38.6 °C (101.5 °F), blood pressure is 150/90 mm Hg, pulse rate is 112/min, and respiration rate is 28/min. Oxygen saturation is 96% breathing ambient air. Crackles are heard at the right lower lung base on pulmonary auscultation. The remainder of the physical examination is normal.

Blood and sputum cultures are obtained. COVID-19 testing is negative.

Chest radiograph shows a right lower lobe infiltrate.

Empiric therapy for community-acquired pneumonia is initiated with ceftriaxone, azithromycin, and vancomycin.

Ceftriaxone and azithromycin are discontinued on hospital day 2 when blood and sputum cultures return positive for methicillin-resistant Staphylococcus aureus with a vancomycin minimum inhibitory concentration of ≤0.5 µg/mL. She remains febrile, but repeat blood and sputum cultures show no growth. Her temperature on hospital day 5 remains elevated at 39.2 °C (102.6 °F).

A repeat chest radiograph shows a right-sided pleural effusion. A subsequent CT scan is shown.


Which of the following is the most appropriate management?


  1. Add cetepime

2- Add gentamicin

3- Perform bronchoscopy with transbronchial biopsy

4- Perform thoracentesis and drainage


Mazen Kherallah
N G
M B

4

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