A 64 year old man presents to the physician’s office complaining of fevers for the past 2 days. Over the past 24 hours, he has developed a productive cough. He also repos that he has frequent chills, and has been waking for the past 2 nights with drenching sweats. His past medical history is remarkable only for mild exeional angina. On physical examination, he does not appear chronically ill but appears moderately dyspneic. His temperature is 38.6 C (101.4 F), blood pressure is 136/94 mm Hg, and respirations are 26/min. There is no jugular venous distention. The lungs have coarse rhonchi at the right lung base with increased fremitus in the same area. He has a regular hea rhythm, with a 1/6 systolic murmur at the left sternal border. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in diagnosis?
Correct Answer: Sputum Gram's stain
Description: This patient has a classic presentation of an acute community acquired bacterial pneumonia, as demonstrated by the findings of acute onset of fevers, rigors, and a productive sputum. His physical examination is consistent with a right lower lobe pneumonia and consolidation in this region. A sputum Gram's stain may demonstrate the organism responsible for this patient's pneumonia. The next step would then be a chest x-ray to confirm the presence of a pneumonia and identify its size and any associated parapneumonic effusions. A chest x-ray film is also indicated, but may take an hour or more to actually be obtained. For this reason, collecting sputum for a Gram's stain, before the x-ray, may shoen the time to definitive therapy. Chest CT scan is usually reserved for evaluation of suspected masses. Pulmonary function tests and peak expiratory flow rate measurement are usually reserved for evaluation of chronic lung diseases, such as emphysema, chronic bronchitis, pulmonary fibrosis, and asthma. Ref: Leeper, Jr. K.V., Moss M. (2003). Chapter 36. Bacterial Pneumonia. In M.E. Hanley, C.H. Welsh (Eds), CURRENT Diagnosis & Treatment in Pulmonary Medicine
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