• 32-year old white female
• Has 5-day hx of fever, SOB, productive cough
• R side pleuritic pain chest pain.
Question #1. What else would you like to ask this patient about her history of present illness and past medical history?
• How many times a year were + for pneumonia? Infections per year? • What was the onset of when this first started taking place? Timeline? • What Antibiotic therapies were used?
• Who is her primary MD? Assuming this is the ER? • Smoking hx?
• Are you having night sweats or chills?
• Inappropriate levels of fatigue? Outside when she is having bouts of pneumonia? • Any recent or past weight loss?
• Any other infections noted? Or any other health problems recently treated?
Question #2. What about her history concerns you, and what else would you like to ask her now?
1). The long history of vaginal yeast infections with an abnormal PAP is concerning.
2). Fatigue coupled with a 7 pound weight not loss is not good either.
3). Also, the fact that how young she is with no apparent cardiac or lung history with a string of pneumonias is an outlier to me?
What I did find interesting is that Brashers (2006) listed her as “[leaving] college 10 years ago.” Often, college is a time of experimentation and for a lot of teens, and young adults, and this involves sex. And I would have asked her about her sexual hx in college, and if she had unprotected sex back then. Further, I am sure Brashers picked 10 years to be exact as Huether and McCance (2008) note, “the average time from infection to development of full-blown AIDS has been estimated at just over 10 years.”
The 2 & 3 joined together are the real sticklers to me.
Question #3. What do you think of her additional history and examination findings?
Occasional night sweats coupled with mild anorexia in the past few months is suggestive of some type of infectious process. (This to me is classic TB or AIDS, as I remember this is textbook sign of symptoms of both from school even 15 years ago was I first started Nursing school.)
Her PPD is very old and needs to be redone and I want a chest X-ray. I would hope to see some type of TB disease process on them if TB is at play!)
No toxin exposure plus 4 partners and unprotected sex has me thinking STD-! But objectively she could have just a strep community acquired pneumonia as she has no occupational hazards; after all, she is an accountant.
I don’t like fact that her, “Pharynx reveals a thick chessy exudate on the soft palate and tongue.” Is this white what does the back of her tongue and throat look like? Is there a white growth on them? Thrush?
I would expect the “palpable cervical adenopathy and T = 39 degrees Celsius” but I would not expect the chessy exudate. And I am not shocked she displays, “Lungs with dullness, increased tactile fremitus, inspiratory crackles, and egophony over the RLL” nor does the “inguinal adenopathy” rock me wrong.
However, I would be upset to see “Thick vaginal discharge and erythema and mild excoriation of the perineum!” She could have 2 infectious processes going on or it could one which is culpable in both? This needs to be explored.
Questions #4 & 5. What diagnostic tests would you obtain? What would you do next? Answer:
6. PAP Smear
8. Hepatitis Serologies
9. Vaginal Smear
Obviously, this patient needs antibiotics and should be treated with such and the vaginal yeast infection must be treated also. And confirmation of HIV status...
References: Barclay, L., (2009). Role of primary care clinicians in HIV management. America Family
Physician; 80, 946-952.
Brashers, V. (2006). Clinical Applications of Pathophysiology (3rd ed.). St. Louis, MO:
Huether, S.E. & McCance, K.L. (2008). Understanding Pathophysiology: Student Guide and
Workbook. (4th ed.). St. Louis, MO:Mosby.
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