Always look at imaging yourself. Always, always, always. I was called for an admission. Young adult, no medical problems, lives in US, no travel, pets, tobacco/drugs/alcohol, no incarceration, periods of homelessness, lives at home with wife and kids and paints for a living.
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3 weeks ago, had flu like symptoms. Toughed it out for a week, came to clinic. Flu negative, given augmentin. Finishes the course but doesn’t get better. Comes to the ER, now symptomatic for 3 weeks. Temp 101, HR 115. Otherwise ambulatory/stable. Vitals wnl after Tylenol.
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CXR read as “RUL Consolodation, Could represent PNA in the right clinical setting.” He’s given 1L bolus, and cultures/CAP abx are ordered. Called for admission for PNA/“Sepsis.” But then I opened up the actual CXR. What do you see?pic.twitter.com/PCMJXFlHnO
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I sprint downstairs, kindly ask the RN to hold off on antibiotics as she’s about to hang them while I get more history. Over the last 3 weeks, night sweats, weight loss, productive cough, indolent progression - playing right into what I was afraid I saw on the CXR.
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Replying to @CNemehMD
great catch with the thorough history- but I would probably agree with the initial CXR read. I think as long as you don’t give levo you’re ok still covering for CAP while waiting for AFBs?
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Replying to @grepmeded
Should be, but there’s some questionable interaction with azithro I believe? He had already completed a course of augmentin which didn’t touch it, and no reason to think he was underdosed/malabsorption or MRSA/PS risk. Given his stability, I was comfortable holding off to be safe
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Replying to @CNemehMD @grepmeded
And I absolutely agree with the initial CXR read, but there’s a subtle cavitation. I also had the luxury of the CT getting done right away and the post-test probability was so high after that I held off antibiotics altogether.
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Replying to @CNemehMD
yep i wondered if I would call the same but think it was retrospectoscope of the CT you showed... but absolutely if you think you see cavitary lesion worth getting the CT
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Replying to @grepmeded
I may have intentionally left out the aggressive back and forths-ing that went into my decision making
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still a great catch. pretty decent chance a pt like this feels better from IVF and placebiotics and goes home with a course of levo the next day with a poor history.
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