G.G., a 59-year-old male, presents to the clinic with complaints of cough, short
ID: 245207 • Letter: G
Question
G.G., a 59-year-old male, presents to the clinic with complaints of cough, shortness of breath, and increased sputum production. His past medical history is significant for COPD with chronic bronchitis, hypertension, diabetes, and hyperlipidemia. He reports that his sputum has increased in consistency and amount over the past few days. His last exacerbation was about 6 months ago, for which he received amoxicillin. This is his third exacerbation in the past year. He has a 40 pack year history of cigarette smoking and quit smoking 3 years ago. He does not take chronic steroids. Physical exam reveals rhonchi and expiratory wheezes. His vital signs are blood pressure 140/83 mm Hg, pulse rate 80 beats/min, respiration rate 20 breaths/min, and temperature 98.8°F. He has no known drug allergies. A sputum Gram stain in the office reveals purulent sputum (presence of WBCs). Chest x-ray findings are negative for pneumonia.
Diagnosis: Acute exacerbation of chronic bronchitis
Which of the following would suggest the need for antibiotic therapy in G.G.?
Cough, history of smoking, and expiratory wheezes on physical examination
Elevated respiratory rate and shortness of breath
Increased dyspnea, increased sputum production, and increased sputum purulence
History of previous COPD exacerbations, cough, and fever
What is a likely pathogen associated with an acute exacerbation of chronic bronchitis in G.G.?
Mycobacterium tuberculosis
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
What antibiotic would be most appropriate to treat an acute exacerbation of chronic bronchitis in G.G.?
Amoxicillin–clavulanate
Azithromycin
Linezolid
Sulfamethoxazole/trimethoprim
Explanation / Answer
1 Increased dyspnea, increased sputum production, and increased sputum purulence - As per, Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, antibiotic should be started in the onset of dyspnea, increased sputum production and sputum purulence.
2. Pseudomonas aeruginosa - it is a commonly seen nosocomial infection affecting the patient with a severe underlying disease ( gram negative rod shaped bacteria). Here the patient chest x-ray shows no evidence of the presence of pneumonia, so the chance of getting affected with the streptococcus pneumonia is less. As the patient has past history of COPD with chronic bronchitis, hypertension, diabetes, and hyperlipidemia, He may have got infected with Pseudomonas aeruginosa.
3 amoxicillin -clavulanate
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