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Case Study: Respiratory Infection Patient Information

Case Study: Respiratory Infection

Patient Information:

• Name: Sarah Smith

• Age: 25

• Gender: Female

• Occupation: Teacher

• Medical History: No significant medical history reported.

Presenting Complaint: Sarah Smith presents to the clinic with complaints of cough, fever, and

difficulty breathing for the past week. She reports a productive cough with yellowish-green

sputum and chest tightness.

Physical Examination Findings:

• Vital Signs: BP 110/70 mmHg, HR 90 bpm, RR 20 breaths/min, Temp 101.2°F

• General: Alert and oriented, appears ill

• Respiratory: Decreased breath sounds and crackles heard bilaterally on auscultation

• Cardiovascular: Regular rhythm, no murmurs or abnormal sounds

• Abdomen: Soft, non-tender, no organomegaly

• Neurological: Intact cranial nerves, normal motor and sensory functions

Laboratory Investigations:

• Complete Blood Count (CBC): Elevated white blood cell count (WBC) with left shift

• Chest X-ray: Infiltrates in bilateral lower lung fields consistent with pneumonia

Diagnosis: Sarah Smith is diagnosed with community-acquired pneumonia based on her clinical

presentation, physical examination findings, and radiological evidence.

Questions for Students:

1. What are the common signs and symptoms of community-acquired pneumonia?

2. Describe the typical findings on physical examination and chest X-ray in patients with

pneumonia.

3. What are the most common pathogens causing community-acquired pneumonia, and

how would you choose empirical antibiotic therapy in this patient?

4. Discuss the management of community-acquired pneumonia, including non-

pharmacological measures and potential complications to monitor for.

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