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Internal Medicine 22: 71-year-old male with cough andfatigueUser:Miranda KingEmail:[email protected]Date:March 8, 2020 1:34AMLearning ObjectivesThe student should be able to:Discuss the common causes of acute dyspnea, their pathophysiology, symptoms, and signs.List the common pneumonia pathogens (viral, bacterial, mycobacterial, and fungal) in immunocompetent andimmunocompromised hosts.Describe radiographic findings associated with specific pathogens.Identify bronchial breath sounds, rales (crackles), rhonchi, and wheezes, signs of pulmonary consolidation, and pleural effusionon physical exam.Recognize the most common complications of pneumonia.Identify /recommend when to order diagnostic laboratory tests—including complete blood count, sputum Gram stain andculture, blood cultures, and arterial blood gases—how to interpret those tests, and how to recommend treatment based onthese interpretations.Select an appropriate empiric antibiotic regimen for community-acquired, nosocomial, immunocompromised-host, andaspiration pneumonia, taking into account pertinent patient features.Discuss the Centers for Medicare and Medicaid Services (CMS) and Joint Commission’s quality measures for smoking cessationadvice and vaccination against pneumonia and influenza in patients with pneumonia and other pulmonary disorders.KnowledgeImportant Historical Findings in a Patient with CoughFeveris an important part of the history in a patient with cough because it makes an infectious cause more likely. The severity offever (e.g., 100.4 vs. 104.0) is not specific and therefore does not help distinguish between different causes of inflammation. Feveris both detrimental and beneficial. It leads to increased metabolism, which can cause dehydration, promote inflammation, andinhibit function of proteins at very high temperatures. The primary potential benefit of fever is to decrease bacterial reproductionand growth, because most bacteria function best in a limited temperature range. Patients are unable to accurately assess theirtemperature based on touch.Chest painneeds to be carefully assessed in patients with cough. Coughing is a violent action, which frequently causes injury tothe intercostal muscles and ribs. Patients with severe coughing spells will often complain of chest pain that is diffuse and bilateralthat occurs primarily with the coughing episode. If the chest pain is due to a pulmonary process, then you can be certain that thepleura are involved and inflamed (because the pulmonary parenchyma is insensate). Such a condition is called pleurisy and thechest pain is worse with deep inspiration or coughing, which is most commonly unilateral.Hemoptysisis a non-specific finding of cough. It is important to determine whether a patient has massive or life-threateninghemoptysis, which is defined as greater than 100 mL over a 24-hour period. Patients often do not estimate the amount of theirhemoptysis accurately, so it is difficult to make this determination by history alone.