Question

A 50-year-old man is admitted to the hospital with a 7-day history of worsening cough, high fever, and dsypnea. On physical examination, he is noted to be tachypneic (respiratory rate of 30 breaths/min), hypoxic with a low oxygen saturation (89%) and febrile (39°C). Chest x-ray film reveals infiltrates in both lower lobes. A complete blood count reveals a white blood cell count of 20,000. Treatment was initiated for community acquired pneumonia. Despite treatment, he experiences worsening hypoxia which requires intubation and ventilatory support. Despite mechanical ventilation using high oxygen concentrations, his arterial blood oxygen level remains low. His chest X-ray film shows progression of infiltrates throughout both lung fields

1. The clinical scenario is most consistent with which diagnosis? You may simply list your answer below using a bullet point format. This does not have to be in a complete sentence.
2. What data in the clinical scenario supports your diagnosis? You may simply list your answers below using a bullet point format. This does not have to be in a complete sentence.
3. What caused the development of the diagnosis you identified in question 1? You may simply list your answer below using a bullet point format. This does not have to be in a complete sentence.
4. Describe the key pathophysiologic concepts. To answer this question completely, you must answer all of the sub-questions below using complete sentences. Each sub-question may be answered in 1-6 sentences.
   1. What are the common causes of the disorder you identified in question 1?
   2. What are the main pathophysiologic factors in the disorder you identified in question 1, that cause the accumulation of extravascular fluid in the lungs?
   3. What accounts for the severe hypoxia associated with the disorder identified in question 1, despite using high oxygen levels and mechanical ventilation?
   4. What is an A-a gradient and what would you expect this patient’s A-a gradient to be?
5. For what actual or potential complications related to the diagnosis in question 1 does she need to be monitored? You may simply list your answer(s) below using a bullet point format. This does not have to be in a complete sentence.

Answer 1

* The scenario would be pneumonia with initial pleural effusion.

* the points which support the diagnosis are:

# tachypnic

# hypoxic

# infiltrates in lobes and lung fields

# persistent cough with lower arterial blood gas levels.

* the initial symptoms which showed the pneumonia and later when treated made it worse and infiltrates shows the pleural effusion.