A 77-year-old man calls the office on a Sunday evening due to fever and cough. The patient has had a "cold" for several days but noticed worsened productive cough, fever, and chills over the last 24 hours. He says "I know it's just a cold and will get better, but my wife worries too much and made me call." The patient has a history of hypertension, chronic kidney disease, chronic obstructive pulmonary disease, and osteoarthritis. He has had to use his albuterol inhaler more frequently during the last few days due to shortness of breath. He has also been taking over-the-counter cough syrup without improvement. The patient is up to date with influenza and pneumococcal vaccines. He is a former smoker and does not use alcohol or illicit drugs. He lives with his wife, who has early-stage dementia. Which of the following is the best next step in management of this patient?

Question

A 77-year-old man calls the office on a Sunday evening due to fever and cough.  The patient has had a "cold" for several days but noticed worsened productive cough, fever, and chills over the last 24 hours.  He says "I know it's just a cold and will get better, but my wife worries too much and made me call."  The patient has a history of hypertension, chronic kidney disease, chronic obstructive pulmonary disease, and osteoarthritis.  He has had to use his albuterol inhaler more frequently during the last few days due to shortness of breath.  He has also been taking over-the-counter cough syrup without improvement.  The patient is up to date with influenza and pneumococcal vaccines.  He is a former smoker and does not use alcohol or illicit drugs.  He lives with his wife, who has early-stage dementia.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf92_c543_8f63_17f7988060f0_MD0005_00 This patient had viral upper respiratory symptoms for several days and now has worsening symptoms. His fever, chills, and productive cough raise concern concern for secondary pneumonia. Secondary pneumonia is a common complication of viral upper respiratory infections. Risk is greatest in patients of advanced age and those with underlying comorbidities (eg, chronic obstructive pulmonary disease [COPD]). Suspicion should be raised when patients with several days of upper respiratory infection symptoms develop worsening fever or pulmonary manifestations (eg, productive cough, dyspnea). Because pneumonia is a serious infection associated with significant morbidity and mortality, urgent evaluation is required. This patient should go to the nearest emergency department (ED) for examination, laboratory studies, and chest x-ray. If pneumonia is present, risk stratification with the pneumonia severity index or CURB-65 score can help determine the appropriate care setting; antibiotics will likely be required. CURB-65 score Even if the patient's symptoms are not due to pneumonia (eg, COPD exacerbation with no infiltrate on x-ray), ED evaluation is appropriate, particularly given the risk of respiratory deterioration with pneumonia. (Choices B and C) Community-acquired pneumonia (CAP) is a serious infection, particularly in patients of advanced age and with underlying pulmonary disease. Evaluation and treatment should not be delayed. (Choice D) Azithromycin monotherapy is sometimes used for CAP in previously healthy patients who are at low risk for complications in areas where macrolide-resistant Streptococcus pneumoniae is uncommon. This patient of advanced age has pulmonary disease (eg, COPD); azithromycin alone would be an insufficient treatment for CAP. Additional clinical data is required prior to hospitalization and treatment decisions. (Choice E) This patient is at high risk for upper viral respiratory infection complications due to his age and underlying lung disease. Because he has worsening symptoms after several days of illness, he requires evaluation for secondary pneumonia. Educational objective: Community-acquired pneumonia commonly occurs after viral upper respiratory infection. Risk is greatest in those of advanced age and with underlying comorbidities (eg, pulmonary disease). Prompt evaluation, imaging, and laboratory studies are required to risk stratify patients and determine the appropriate level of care.

A 77-Year-Old Man Calls the Office on a Sunday Evening