A primary care physician is evaluating a 52-year-old man who presents with a productive co… — USMLE Step 3

A primary care physician is evaluating a $52$ -year-old man who presents with a productive cough, subjective fevers, and fatigue lasting for four days. The patient has no significant past medical history and takes no daily medications. On examination, he is alert and cooperative. His temperature is $38.4^{\circ}\text{C}$ ( $101.1^{\circ}\text{F}$ ), blood pressure is $124/78\text{ mmHg}$ , pulse is $88/\text{min}$ , and respiratory rate is $18/\text{min}$ . Oxygen saturation is $97\%$ on ambient air. Auscultation of the lungs reveals crackles in the left lower base. Point-of-care laboratory testing shows a blood urea nitrogen level of $12\text{ mg/dL}$ . A chest radiograph demonstrates a left lower lobe consolidation. The patient is able to drink fluids without difficulty and lives at home with his healthy spouse. Based on clinical risk stratification, which of the following is the most appropriate disposition for this patient?

Discharge home with a prescription for oral antibioticsAnswer
B
Admission to a general medical ward for intravenous antibiotics
C
Admission to the intensive care unit for frequent respiratory assessments
D
Transfer to a skilled nursing facility for administration of intravenous antibiotics
E
Placement in an observation unit to await a repeat chest radiograph in $24$ hours

Answer

Discharge home with a prescription for oral antibiotics

The most appropriate disposition is discharging the patient home with a prescription for oral antibiotics. This patient has community-acquired pneumonia (CAP) with a CURB-65 score of

0

. He does not exhibit confusion, his blood urea nitrogen is

<19\text{ mg/dL}

, his respiratory rate is

<30/\text{min}

, his blood pressure is normal (systolic

\geq 90\text{ mmHg}

and diastolic

\geq 60\text{ mmHg}

), and his age is

<65

years. A CURB-65 score of

0

indicates a very low risk of 30-day mortality. Standard clinical guidelines recommend that such low-risk patients be treated in an outpatient setting, provided they are able to maintain oral intake, do not have severe hypoxemia, and possess reliable outpatient support, all of which are present in this case.

Step-by-Step Solution

Assess pneumonia severity using the CURB-65 criteria.

The score is

0

because the patient is under

65

years old, is fully alert, has a blood urea nitrogen

< 19\text{ mg/dL}

, respiratory rate

< 30/\text{min}

, and stable blood pressure.

Objective risk stratification is required to determine the safest and most appropriate care setting.

Evaluate the patient's functional and social status.

The patient tolerates oral fluids and has reliable home support.

To confirm that outpatient management is practically feasible and safe.

Determine the optimal disposition.

The patient should be discharged home.

Clinical guidelines recommend outpatient care with oral antibiotics for a CURB-65 score of

0

1

Key Concept

Disposition of community-acquired pneumonia using the CURB-65 severity score

Estimated Time:1m 0s

Question

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