Mr. Gasper, a 66-year-old retired insurance salesman, was a heavyset, barrel-chested man. When he came to your office he was too short of breath to talk, so his wife gave you his medical history. The onset of the illness was 5 days ago, and had started with fever, generalized myalgia, headache, and a moderately severe, non-productive cough. Over the next several days, the fever rose and the cough became more severe. Today the cough was persistent and was accompanied by some blood-tinged sputum. The cough was not accompanied by chest pain. You note with some surprise that although the patient is quite short of breath, he lights up a cigarette. His wife says he has smoked a pack of cigarettes a day all of his adult life.
Question 1 - Single Best Answer
What are some organisms that you particularly worry about in the elderly? Bugs Database
parainfluenza virus, respiratory syncytial virus, Coxsackie virus Streptococcus agalactiae, Chlamydia trachomatis, papilloma virus Campylobacter fetus, Listeria monocytogenes, rotavirus Influenza virus, Legionella pneumophila, Streptococcus pneumonia
Question 2 - Single Best Answer
Headache, fever, and myalgia could signal infection with which of the following? Bugs Database
influenza or viral encephalitis malaria or Hanta virus infection legionellosis or influenza Lyme disease or Legionnaire's disease any of the above
Question 3 - Single Best Answer
The sputum in pneumococcal pneumonia is usually described as? Bugs Database
currant jelly frothy white blood tinged rust colored
Question 4 - Single Best Answer
What information, besides medical information, would be important in diagnosing this man's illness? Bugs Database
time of year geographical location hobbies travel all of the above
It is November in Florida. Although no cases of flu have been reported in your area, both Jacksonville and Miami have been reporting an increased number of flu cases. Mr. Gasper had a myocardial infarct 6 years ago and has experienced a progressive decrease in his physical and intellectual abilities over that past two or three years. Although he used to be an active hunter, he hardly ever goes out anymore. He has not traveled out of the area recently. He also does not keep any cats, dogs, or birds at home. He has not received a flu vaccine or the multivalent pneumococcal vaccine.
Question 5 - Single Best Answer
The fact that it is flu season and he hasn't been vaccinated is very worrisome to you. How could the flu virus cause this man's problems? Bugs Database
it could denude the ciliated tracheal epithelium he could have bacterial pneumonia which not infrequently follows influenza he could have primary influenza pneumonia all of the above
Question 6 - Single Best Answer
Considering all the information you have so far, which of the following do you consider most likely? Bugs Database
influenza pneumonia or pneumococcal pneumonia influenza (URT infection) or Legionnaire's disease staphylococcal or herpes pneumonia psittacosis or legionellosis Hanta virus infection or Lyme disease
Physical exam showed the following:
He was cyanotic, and his neck veins were distended, especially during expiration. Moist, crepitant rales were heard posteriorly below both scapulas. No heart murmurs or focal neurological signs were noted. He had not been nauseated or had diarrhea.
Question 7 - Single Best Answer
What is the significance, if any, of the fact that he has not been nauseated? Bugs Database
pneumonia is always accompanied by nausea viral infections are always accompanied by nausea Legionnaire's disease is frequently accompanied by nausea it is of no significance
Question 8 - Single Best Answer
What are rales? Bugs Database
continuous rumbling sounds in the lungs a high-pitched musical sound heard on expiration a high-pitched musical sound heard on inspiration discontinuous bubbling sounds in the lungs
Question 9 - Single Best Answer
What is the cause of rales or crackles? Bugs Database
airway obstructed by thick secretions or muscle spasm air entering alveoli that contain serous secretions an obstructed trachea or larynx
Question 10 - Single Best Answer
What should you do next? Bugs Database
prescribe aspirin and rest as there is nothing you can do for flu give penicillin and send him home do a sputum Gram stain give amantadine do a serologic test for Legionella
Chest x-rays showed bilateral densities in the left lower and right upper lobes and 15% cardiomegaly. No changes from previous tracings were seen when an electrocardiogram was made. White count was 13,000. Oxygen saturation of the blood was 80%. A sputum gram stain showed a few Gram positive and a few Gram negative organisms of varying morphologies. Normal Lab Values
Question 11 - Single Best Answer
The sputum Gram stain means? Bugs Database
he has congestive heart failure he doesn't have bacterial pneumonia he has Legionnaire's disease he has tuberculosis the sputum is contaminated with saliva
Question 12 - Single Best Answer
The lung consolidation seen in the x-ray means which of the following? Bugs Database
he has bacterial pneumonia he might have viral pneumonia he has Legionnaire's disease
Question 13 - Single Best Answer
Which of the following tests should you now order? Bugs Database
sputum culture for bacteria Legionella antigen test influenza virus isolation blood culture all of the above
Mr. Gasper was admitted to the hospital. He was treated vigorously with cefazolin and given oxygen at a flow of 10 liters per minute. In spite of the best possible care the patient died. The results of lab tests done before he died showed the following: sputum culture -- only normal oral and pharyngeal flora; blood culture -- negative; Legionella antigen test -- negative. A transtracheal aspirate grew influenza A virus.
Question 14 - Single Best Answer
What did Mr. Gasper die of? Bugs Database
primary influenza virus pneumonia bacterial pneumonia subsequent to influenza Legionnaire's disease Reye's syndrome
Primary influenza pneumonia usually occurs in middle-aged or older patients with chronic pulmonary disease or organic heart disease. The onset may be typical of severe uncomplicated "flu" but the patient will, in the next 24-48 hours experience increasing respiratory distress. The cough, although non-productive at first, becomes productive of sputum that is frothy and blood-tinged. Pulmonary findings may be diffuse, with no signs of local consolidation. Later in the disease consolidation may appear. The course of influenza pneumonia is rapid and the prognosis is poor. Patients respond to neither antibiotics nor steroids. Death is due to anoxia.