A 45-year-old woman comes to the office for routine follow-up. Six weeks ago, the patient was admitted to the hospital for treatment of left lower lobe pneumonia. After receiving intravenous antibiotic therapy for 3 days, she was sent home to finish a 7-day course of oral moxifloxacin. Since discharge, the patient has felt well. She reports getting her energy back and being able to perform daily activities without difficulty. The patient has a 15-pack-year history but stopped smoking after the pneumonia. She does not drink alcohol. Vital signs are normal. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

Question

A 45-year-old woman comes to the office for routine follow-up.  Six weeks ago, the patient was admitted to the hospital for treatment of left lower lobe pneumonia.  After receiving intravenous antibiotic therapy for 3 days, she was sent home to finish a 7-day course of oral moxifloxacin.  Since discharge, the patient has felt well.  She reports getting her energy back and being able to perform daily activities without difficulty.  The patient has a 15-pack-year history but stopped smoking after the pneumonia.  She does not drink alcohol.  Vital signs are normal.  Physical examination shows no abnormalities.  Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient was treated for community-acquired pneumonia (CAP) with a respiratory fluroquinolone. Follow-up 6 weeks later shows a resolution of symptoms, normal vital signs, and no residual pulmonary findings. Guidelines published jointly by the American Thoracic Society and the Infectious Diseases Society of America indicate that patients who respond appropriately to antibiotic therapy (eg, 7 days) for CAP do not require additional laboratory testing or radiographic imaging. In contrast, patients who do not completely respond to antibiotic therapy generally require additional evaluation for loculated infection (eg, empyema), atypical pathogens (eg, Mycobacterium tuberculosis), or other lung pathology (eg, malignancy, inflammatory lung disease). (Choice A) Patients with CAP who have resolution of symptoms with antibiotic therapy do not require follow-up chest x-ray. When symptoms do not improve or completely resolve, additional pulmonary imaging (eg, chest x-ray, CT scan) is generally required. (Choice B) The utility of procalcitonin and C-reactive protein (CRP) in distinguishing bacterial from nonbacterial causes of pneumonia has been evaluated in some studies; however, there is no established role for CRP testing in follow-up for CAP. (Choice C) Patients age 50-80 who have a ≥20-pack-year history and currently use tobacco or quit within the past 15 years should undergo low-dose CT scan of the chest annually to evaluate for lung cancer. This patient is below both the recommended age and smoking history threshold to begin regular low-dose CT scan. (Choice D) For patients with deep venous thrombosis in whom the benefits of indefinite anticoagulation are unclear, D-dimer testing may be helpful. In metaanalyses, a level that was elevated 3 months after stopping anticoagulation was associated with a high risk of recurrence. Educational objective: Patients who respond to antibiotic therapy for community-acquired pneumonia do not require follow-up imaging or laboratory testing. However, patients age 50-80 who have a ≥20-pack-year history and currently use tobacco or quit within the past 15 years should undergo annual low-dose CT scan to evaluate for malignancy. __________ References: Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America (http://www.ncbi.nlm.nih.gov/pubmed/31573350)

A 45-Year-Old Woman Comes to the Office for Routine Follow-Up