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Joe Gasper

   Mr. Gasper, a 66-year-old retired insurance salesman, was a heavyset, barrel-chested man. When he came to your office he was too short of breath to talk, so his wife gave you his medical history. The onset of the illness was 5 days ago, and had started with fever, generalized myalgia, headache, and a moderately severe, non-productive cough. Over the next several days, the fever rose and the cough became more severe. Today the cough was persistent and was accompanied by some blood-tinged sputum. The cough was not accompanied by chest pain. You note with some surprise that although the patient is quite short of breath, he lights up a cigarette. His wife says he has smoked a pack of cigarettes a day all of his adult life.

Question 1 - Single Best Answer

What are some organisms that you particularly worry about in the elderly?   

A) parainfluenza virus, respiratory syncytial virus, Coxsackie virus
B) Streptococcus agalactiae, Chlamydia trachomatis, papilloma virus
C) Campylobacter fetus, Listeria monocytogenes, rotavirus
D) Influenza virus, Legionella pneumophila, Streptococcus pneumonia

Question 2 - Single Best Answer

Headache, fever, and myalgia could signal infection with which of the following?   

A) influenza or viral encephalitis
B) malaria or Hanta virus infection
C) legionellosis or influenza
D) Lyme disease or Legionnaire's disease
E) any of the above

Question 3 - Single Best Answer

The sputum in pneumococcal pneumonia is usually described as?   

A) currant jelly
B) frothy white
C) blood tinged
D) rust colored

Question 4 - Single Best Answer

What information, besides medical information, would be important in diagnosing this man's illness?   

A) time of year
B) geographical location
C) hobbies
D) travel
E) all of the above

It is November in Florida. Although no cases of flu have been reported in your area, both Jacksonville and Miami have been reporting an increased number of flu cases. Mr. Gasper had a myocardial infarct 6 years ago and has experienced a progressive decrease in his physical and intellectual abilities over that past two or three years. Although he used to be an active hunter, he hardly ever goes out anymore. He has not traveled out of the area recently. He also does not keep any cats, dogs, or birds at home. He has not received a flu vaccine or the multivalent pneumococcal vaccine.

Question 5 - Single Best Answer

The fact that it is flu season and he hasn't been vaccinated is very worrisome to you. How could the flu virus cause this man's problems?   

A) it could denude the ciliated tracheal epithelium
B) he could have bacterial pneumonia which not infrequently follows influenza
C) he could have primary influenza pneumonia
D) all of the above

Question 6 - Single Best Answer

Considering all the information you have so far, which of the following do you consider most likely?   

A) influenza pneumonia or pneumococcal pneumonia
B) influenza (URT infection) or Legionnaire's disease
C) staphylococcal or herpes pneumonia
D) psittacosis or legionellosis
E) Hanta virus infection or Lyme disease

Physical exam showed the following:

He was cyanotic, and his neck veins were distended, especially during expiration. Moist, crepitant rales were heard posteriorly below both scapulas. No heart murmurs or focal neurological signs were noted. He had not been nauseated or had diarrhea.

Question 7 - Single Best Answer

What is the significance, if any, of the fact that he has not been nauseated?   

A) pneumonia is always accompanied by nausea
B) viral infections are always accompanied by nausea
C) Legionnaire's disease is frequently accompanied by nausea
D) it is of no significance

Question 8 - Single Best Answer

What are rales?   

A) continuous rumbling sounds in the lungs
B) a high-pitched musical sound heard on expiration
C) a high-pitched musical sound heard on inspiration
D) discontinuous bubbling sounds in the lungs

Question 9 - Single Best Answer

What is the cause of rales or crackles?   

A) airway obstructed by thick secretions or muscle spasm
B) air entering alveoli that contain serous secretions
C) an obstructed trachea or larynx

Question 10 - Single Best Answer

What should you do next?   

A) prescribe aspirin and rest as there is nothing you can do for flu
B) give penicillin and send him home
C) do a sputum Gram stain
D) give amantadine
E) do a serologic test for Legionella

Chest x-rays showed bilateral densities in the left lower and right upper lobes and 15% cardiomegaly. No changes from previous tracings were seen when an electrocardiogram was made. White count was 13,000. Oxygen saturation of the blood was 80%. A sputum gram stain showed a few Gram positive and a few Gram negative organisms of varying morphologies. Normal Lab Values

Question 11 - Single Best Answer

The sputum Gram stain means?   

A) he has congestive heart failure
B) he doesn't have bacterial pneumonia
C) he has Legionnaire's disease
D) he has tuberculosis
E) the sputum is contaminated with saliva

Question 12 - Single Best Answer

The lung consolidation seen in the x-ray means which of the following?   

A) he has bacterial pneumonia
B) he might have viral pneumonia
C) he has Legionnaire's disease

Question 13 - Single Best Answer

Which of the following tests should you now order?   

A) sputum culture for bacteria
B) Legionella antigen test
C) influenza virus isolation
D) blood culture
E) all of the above

Mr. Gasper was admitted to the hospital. He was treated vigorously with cefazolin and given oxygen at a flow of 10 liters per minute. In spite of the best possible care the patient died. The results of lab tests done before he died showed the following: sputum culture -- only normal oral and pharyngeal flora; blood culture -- negative; Legionella antigen test -- negative. A transtracheal aspirate grew influenza A virus.

Question 14 - Single Best Answer

What did Mr. Gasper die of?   

A) primary influenza virus pneumonia
B) bacterial pneumonia subsequent to influenza
C) Legionnaire's disease
D) Reye's syndrome

Primary influenza pneumonia usually occurs in middle-aged or older patients with chronic pulmonary disease or organic heart disease. The onset may be typical of severe uncomplicated "flu" but the patient will, in the next 24-48 hours experience increasing respiratory distress. The cough, although non-productive at first, becomes productive of sputum that is frothy and blood-tinged. Pulmonary findings may be diffuse, with no signs of local consolidation. Later in the disease consolidation may appear. The course of influenza pneumonia is rapid and the prognosis is poor. Patients respond to neither antibiotics nor steroids. Death is due to anoxia.