The patient is treated with intravenous fluids and antibiotics, with improvement in fever, leukocytosis, and hypotension. On the third day of hospitalization, temperature is 36.7 C (98 F), blood pressure is 122/78 mm Hg, and pulse is 86/min. On examination, he is mildly lethargic and his voice is soft and breathy. Rhonchi are still heard over the lower right lung. There is left-sided facial droop and hemiparesis from his previous stroke. Chest x-ray demonstrates dense air space opacities in the superior region of the right lower lobe. Which of the following is the most likely underlying etiology of this patient's hospitalization?

Question

The patient is treated with intravenous fluids and antibiotics, with improvement in fever, leukocytosis, and hypotension.  On the third day of hospitalization, temperature is 36.7 C (98 F), blood pressure is 122/78 mm Hg, and pulse is 86/min.  On examination, he is mildly lethargic and his voice is soft and breathy.  Rhonchi are still heard over the lower right lung.  There is left-sided facial droop and hemiparesis from his previous stroke.  Chest x-ray demonstrates dense air space opacities in the superior region of the right lower lobe.  Which of the following is the most likely underlying etiology of this patient's hospitalization?

Quizplus · Accepted Answer

11ec160b_3a07_221e_9249_731081f51346_MD0001_00 This patient developed septic shock secondary to pneumonia (rhonchi on lung examination and radiographic lung opacities). His history of dementia and stroke with residual hemiparesis and evidence of vocal cord paralysis (soft, breathy voice) is highly suggestive of aspiration pneumonia due to inhalation of oral secretions. The superior regions of the lower lobes and posterior regions of the upper lobes are the most dependent locations in the lungs of supine individuals. Infiltrates in these locations revealed on chest x-ray are further evidence of aspiration pneumonia. Anaerobic bacteria (Peptostreptococcus, Bacteroides, Prevotella, Fusobacterium) are the dominant organisms in the oral cavity and may be isolated from cultures from patients with aspiration pneumonia. (Choice A) Enteral feeding, specifically oral intake, increases the risk of aspiration in patients with dysphagia. (Choices B and D) Reduced intercostal muscle strength can result in atelectasis and hypoxia. Extended immobility can produce atelectasis in the posterior lungs if the patient remains in a supine position. These conditions can also predispose to the development of pneumonia if pulmonary hygiene is inadequate. However, aspiration pneumonia is less likely in such patients as long as swallow and cough reflexes are intact. (Choice C) Impaired cellular immunity usually results in recurrent viral and fungal infections. Educational objective: Elderly patients with dementia or hemiparesis may have dysphagia, which is a risk factor for aspiration pneumonia. Dependent lung consolidation is commonly seen in aspiration pneumonia.

The Patient Is Treated with Intravenous Fluids and Antibiotics, with Improvement