Clinical Pearl Blog: 54-year-old male w/ fever, malaise, cough

Gerard Kiernan, MD, FAAFP, FHMClinical Pearl of the Month, Emergency Medicine, Family Medicine, Internal Medicine, Nurse Practitioner, Nursing RN/PN, Urgent Care

Clinical Pearl Blog from MedChallenger medical education

Test your clinical knowledge with this clinical pearl of the month review question.

Clinical Scenario

A 54-year-old man presents in follow-up from an emergency department (ED) visit a day prior. He was told to see his doctor for a recheck, after presenting to the ED with fever, malaise, and occasional cough.

The patient is a long-time smoker of a pack per day. His chronic medical problems include hypertension, hyperlipidemia, and low back pain.

In the emergency department, he was found to have a white blood cell (WBC) count of 16,000 WBC/mm3, with a neutrophil predominance.

He was afebrile when seen, but said that the prior evening he had chills and the feeling of fever.

His chest x-ray was negative, but some wheezing was noted on exam. He was discharged with a prescription for doxycycline 100mg PO for five days for a presumed COPD exacerbation and asked to follow-up with his PCP.

In clinic, the patient is non-toxic appearing and afebrile. He says that, after returning home from the ED, he still felt tired and had some chills, but perhaps not as much as the night prior.

His blood pressure is 132/76 mm Hg. He denies headache, nausea, or vomiting, but still has some occasional nonproductive cough.

On examination, he still has some wheezes on lung exam, but no other findings. No heart murmur or petechial rash is noted.

A review of the electronic medical record (EMR) shows that blood cultures drawn the day prior, in the ED, were both positive for gram positive cocci in clusters.

Question

How should this patient be managed at this point?

Answer Options:

Continue the current doxycycline treatment but extend course to ten days.

Change the antibiotic to levofloxacin orally and see patient in two days for reevaluation.

Hospitalize for intravenous vancomycin therapy, echocardiogram, and Infectious Disease consultation.

Change therapy to once daily intravenous ceftriaxone and arrange outpatient CT scan of chest, abdomen and pelvis.

See the Answer:


About the Author:

Gerard Kiernan, MD, FAAFP, FHM is a Dartmouth-Hitchcock Clinic hospitalist in Keene, NH. He attended the University of Rochester School of Medicine and Dentistry, followed by a Family Medicine residency at the University of Wisconsin, Madison, where he was a chief resident. Dr. Kiernan is a Lean Six Sigma Greenbelt and has led hospital medicine quality improvement efforts. He is a fellow of both the American Academy of Family Physicians and the Society of Hospital Medicine. He has achieved the Recognition of Focused Practice in Hospital Medicine offered through the AAFP and ABIM via their joint examination pathway.

About Clinical Pearl of the Month:

Med-Challenger‘s Clinical Pearl Blog Series is a recurring segment of Med-Challenger’s popular Medical Education Blog. Med-Challenger provides online medical education products and services to physicians, nurses, and other medical specialists as well as medical training programs and healthcare groups world-wide via its web-based medical education library and world-class assessment platform at challengercme.com.

You can sign up free and start a free trial of any board review, CME course, or group application.


More from Med-Challenger

The Leader in Online Board Review, CME Courses, and Medical Education

Did you like this?
Get more Clinical Pearl patient scenarios!

SubscribeGet new challenges & more

More from the Med-Challenger Blog

Current Special Offers

Online medical education, the best board review, and career MOC solutions for clinicians.

Limited time special offers.

Spring CME Event
SAVE 15%

Get Coupon

Best Budget idea?
Stop the MOC pain. Go PRO.

Cover your needs once and for all with a Med-Challenger PRO bundle!

Take 20% off your PRO instantly
- or -
get your PRO with 2 yrs free access + a $1000 free Amazon gift card with a CME FLEX package.

Best online medical education courses on sale. Image

Buy once. Save up to 55%!

EVERYTHING
in your specialty.

See available PRO package options.
One-time purchase. Always useful.
Ideal use your CME budget.

View CME Flex Options View PRO Options

Already own Med-Challenger?
Credit your previous purchases and upgrade to PRO for less!
Email sales@chall.com about current customer UPGRADE PRICING.

Shop all Med-Challenger products in our store.

Shop ProductsBoard review & MOC made easy