Family Medicine, Internal Medicine and Surgery Case 4 answer

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Iowa Lutheran Family Medicine Residency Program

PIAC Case Series


Case 04 - Crystal, 45 years of age

Crystal is a 45 y/o obese WF who undergoes laparoscopic cholecystectomy; she is admitted postop with poorly controlled pain. She has COPD and smokes 2 ppd.

On postop day 2 the patient develops a fever to 38.9 and cough; CXR shows new LLL infiltrate


1)  What were Crystal's predisposing risk factors for HCAP (health care associated pneumonia)?

  • What are the likely causative organisms?
  • What preventative measures are utilized to prevent HCAP?


  • Predisposing risk factors:
    • For Crystal - pre-existing lung disease, smoking, recent intubation
    • Other risk factors - over-sedation, PPI use, aspiration
  • Likely causative organisms:
    • Early onset: Strep pneumo, hemophilus, moraxella,
    • Late onset (hospital day 5 or later): aerobic gram neg bacilli (Pseudomonas, Enterobacter, etc.), Staph aureus (esp MRSA)
  • Preventative measures:
    • Early ambulation
    • Incentive spirometry
    • Judicious use of PPI
    • Measures to decrease risk of aspiration

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