Correct!
5. Treatment for presumed community-acquired pneumonia with imaging follow up to show resolution
Absent other atypical clinical features or extenuating circumstances, it is appropriate to treat a presumed community-acquired pneumonia and re-evaluate the patient following treatment. The time interval required for imaging follow up to show clearing of a presumed pneumonia detected at chest radiography is variable. In older patients, it is not uncommon for opacities related to pulmonary infection detected at imaging to be visualized for several months, whereas in other patients, sometimes the opacities will resolve quickly. Typically repeat imaging is not required for several weeks at least, unless clinical symptoms worsen or assessment suggests the original diagnosis was incorrect or a complication may be developing. 99mTc-MAA ventilation-perfusion scintigraphy is useful for the detection of suspected thromboembolic disease and is not a “wrong” answer, but pulmonary embolism is not highly suspected in this patient and therefore 99mTc-MAA ventilation-perfusion scintigraphy is not the most appropriate next step. Thoracic MRI plays essentially no role in the assessment of patients with focal pulmonary opacities- the signal obtained from lung at thoracic MRI is rather poor and when advanced imaging is needed, CT is faster, better tolerated, and generally more rewarding. 68Ga-citrate scintigraphy is occasionally used for assessment of diffuse lung opacities, perhaps to detect opportunistic infections in immunocompromised patients, or pneumonitis related to medication-induced pulmonary injury, but neither are appropriate considerations for this patient. Decubitus chest radiography is useful for detection of pleural fluid (on the dependent side) or pneumothorax (on the non-dependent side), but neither complication is suspected in this case).
Further clinical course: Over the next few days that patient complained of worsening cough and blood-streaked sputum.
Which of the following represents the next most appropriate step for the evaluation of this patient? (Click on the correct answer to proceed to the sixth of nine panels)