Pneumonia Case Studies A 73-year-old white male has been experiencing shortness of breath and left-sided chest pain for the last 24 hours. More recently, he has noted shaking chills and a fever. About 3 days before, he had been drinking alcohol excessively and passed out. When he awoke, he noted vomitus on his shirt. He does have a history of hypertension and coronary artery disease. His physical examination indicated that he was tachypneic and had a fever. His heart rate was 110 per minute. His chest examination demonstrated rhonchi in the lower lateral left chest. Studies Results Routine laboratory work Normal except for elevated WBC equal 18,000 with 88% neutrophils Chest X-ray study, p. 1014 Pulmonary opacity in the left lower lung field. Arterial blood gasses (ABGs), p. 109 pH 7.39 (normal: 7.35-7.45) Pco2 36 mm Hg (normal: 35-45 mm Hg) Po2 79 mm Hg (normal: 80-100 mm Hg) HCO3: 23 mEq/L (normal: 22-26 mEq/L) B-type natriuretic peptide (BNP), p. 367
78 pg/mL (normal: <100) EKG, p. 544 No evidence of ischemic disease Blood cultures, p. 708 Positive for Klebsiella Sputum culture, p. 761 Positive for Klebsiella AST, ALT, LDH, alk phos, p. 47 All mildly elevated liver enzymes Diagnostic Analysis The cause of shortness of breath in this older adult male could be myocardial ischemia, congestive heart failure, pneumonia, or pulmonary embolism. His history of having vomited while unconscious raises the suspicion of aspiration pneumonia. His high WBC and the fever are more compatible with infection. His normal BNP excludes the possibility of congestive heart failure. His chest X-ray demonstrates classic aspiration pneumonia. Critical Thinking Questions 1. What are some other tests that could help delineate the cause of shortness of breath? 2. To what antibiotic is Klebsiella commonly sensitive? 3. Should antibiotics be provided empirically upon the initial visit or should antibiotics be withheld until culture and sensitivity reports are available? 4. What are the potential social problems associated with this man's care and future discharge? 5. What do the abnormal liver enzymes tell you about his alcohol use?