Subinternship Medicine · Year 4 · from Subinternship Medicine

Case 1: Community-Acquired Pneumonia with Time Management Challenge

Clinical Presentation

Patient Demographics: 58-year-old male

Chief Complaint: "I've had a cough and fever for 4 days"

History of Present Illness: Mr. Thompson is a 58-year-old male with a history of type 2 diabetes mellitus and hypertension who presents to the emergency department with a 4-day history of productive cough with yellow-green sputum, fever to 38.9C at home, progressive dyspnea, and right-sided pleuritic chest pain. He reports decreased oral intake over the past 2 days and notes that his symptoms have worsened despite taking over-the-counter cough suppressants.

Past Medical History:

  • Type 2 diabetes mellitus (A1c 7.8% three months ago)
  • Hypertension
  • Hyperlipidemia

Medications:

  • Metformin 1000 mg twice daily
  • Lisinopril 20 mg daily
  • Atorvastatin 40 mg daily

Social History:

  • Former smoker (quit 5 years ago, 20 pack-year history)
  • No alcohol use
  • Retired factory worker
  • Lives with wife

Physical Examination:

  • Vital Signs: Temperature 38.7C, HR 102 bpm, BP 128/78 mmHg, RR 22/min, SpO2 92% on room air
  • General: Appears ill, mild respiratory distress
  • HEENT: Dry mucous membranes
  • Lungs: Decreased breath sounds at the right base with dullness to percussion; bronchial breath sounds and egophony in the right lower lobe
  • Cardiovascular: Tachycardic, regular rhythm, no murmurs
  • Abdomen: Soft, non-tender
  • Extremities: No edema

Inpatient Workup

Laboratory Studies:

  • WBC 16,800/uL with 85% neutrophils, 8% bands
  • Hemoglobin 13.2 g/dL
  • Platelets 342,000/uL
  • BUN 28 mg/dL, Creatinine 1.4 mg/dL (baseline 1.0)
  • Sodium 136 mEq/L, Potassium 4.2 mEq/L
  • Glucose 198 mg/dL
  • Procalcitonin 2.4 ng/mL
  • Lactate 1.8 mmol/L

Imaging:

  • Chest X-ray: Right lower lobe consolidation with air bronchograms consistent with lobar pneumonia

Microbiology:

  • Blood cultures x 2 obtained
  • Sputum culture obtained
  • Legionella urinary antigen: Negative
  • Streptococcus pneumoniae urinary antigen: Positive

Diagnosis

Primary Diagnosis: Community-acquired pneumonia (Streptococcus pneumoniae), right lower lobe

Secondary Diagnoses:

  • Acute kidney injury (pre-renal, likely dehydration)
  • Type 2 diabetes mellitus with hyperglycemia

Treatment Plan

Immediate Management:

  1. Admit to medicine floor (CURB-65 score: 2)
  2. Supplemental oxygen via nasal cannula to maintain SpO2 > 92%
  3. IV fluid resuscitation with normal saline
  4. Ceftriaxone 1g IV daily + Azithromycin 500 mg IV daily
  5. Hold metformin given AKI
  6. Insulin sliding scale for glucose management
  7. DVT prophylaxis with subcutaneous heparin

Monitoring:

  • Daily weights
  • Strict intake and output
  • Renal function monitoring
  • Respiratory status assessment

Sub-Intern Learning Points: This case illustrates several key sub-intern responsibilities:

  1. Time Management: Prioritizing this patient's admission workup while managing other patients on the team
  2. Clinical Decision-Making: Recognizing severity markers (tachypnea, hypoxia, AKI) that warrant inpatient admission
  3. Order Writing: Writing comprehensive admission orders including antibiotics, fluids, and prophylaxis
  4. Communication: Staffing the case with the senior resident and attending, presenting the assessment and plan
  5. Autonomy Building: Proposing the antibiotic regimen before asking for guidance

Clinical Image

Image Description: Chest radiograph demonstrating right lower lobe consolidation with air bronchograms, characteristic of lobar pneumonia.

Image Source: Wikimedia Commons - "X-ray of lobar pneumonia"

  • URL: https://commons.wikimedia.org/wiki/File:X-ray_of_lobar_pneumonia.jpg
  • License: Creative Commons Attribution-Share Alike 4.0 International
  • Author: Mikael Haggstrom, M.D.

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