P CBD X Think beyond the cough: spot the subtle signs of atypical pneumonia

 A

Here’s a structured interactive quiz format for your case:

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Case Presentation

Patient: 12-year-old boy, previously healthy
Chief Complaints:

• Headaches for 2 weeks

• Malaise and fatigue

• Fever
  Additional History:

• Nonproductive cough

• No significant past medical history

• Up-to-date on vaccinations

• No recent travel or sick contacts

Vitals on Presentation:

• Temp: 38.5°C

• HR: 100 bpm

• RR: 22/min

• BP: 105/65 mmHg

• O₂ Sat: 98% on room air

Physical Exam:

• Appears tired, mildly ill

• Throat mildly erythematous

• Lungs: Clear to auscultation

• No lymphadenopathy

• No rash

• Neurologic exam: Non-focal, slightly photophobic

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Step 1: Initial Considerations

Question: Based on the presentation, what are your top 3 differential diagnoses?

Hints:

• Fever + headache + malaise

• Nonproductive cough

• Duration: 2 weeks

Possible Choices:
A. Viral upper respiratory infection (URI)
B. Influenza
C. COVID-19
D. Atypical pneumonia (e.g., Mycoplasma)
E. Bacterial meningitis
F. Mononucleosis (EBV)

(Correct answers: D and possibly F; bacterial meningitis less likely given mild neurologic signs and no acute distress.)

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Step 2: Initial Workup

Question: Which labs or tests would you order?

Options:

• CBC, ESR, CRP

• Basic metabolic panel

• Chest X-ray

• Throat swab / PCR for respiratory pathogens

• Blood cultures

• Lumbar puncture

Rationale:

• CBC and inflammatory markers help assess infection severity.

• Chest X-ray can detect atypical pneumonia.

• Blood cultures if persistent fever.

• Lumbar puncture only if signs of meningitis (neck stiffness, severe headache, altered mental status).

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Step 3: Interpreting Findings

Scenario:

• CBC: Mild leukocytosis

• ESR/CRP: Mildly elevated

• Chest X-ray: Patchy infiltrates in right lower lobe

• Throat swab: Negative for strep

Question: What is the most likely diagnosis?

Answer: Atypical pneumonia (likely Mycoplasma pneumoniae)

Rationale:

• Subacute course (2 weeks)

• Nonproductive cough

• Mild systemic symptoms

• Patchy infiltrates on CXR

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Step 4: Management

Question: What is the treatment of choice?

Answer Options:
A. Amoxicillin
B. Azithromycin
C. Ceftriaxone
D. Supportive care only

Correct Answer: B. Azithromycin

• Mycoplasma lacks a cell wall → beta-lactams (amoxicillin) ineffective

• Macrolides or doxycycline (in older children/adolescents) are first-line

Additional Management:

• Symptomatic relief: antipyretics for fever, hydration

• Follow-up in 48–72 hours to ensure improvement

• Educate family on warning signs: worsening cough, shortness of breath, persistent high fever

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Step 5: Key Teaching Points

1. Subacute fever + headache + malaise + nonproductive cough in school-age children often points to atypical pneumonia.

2. Chest X-ray findings may show patchy or interstitial infiltrates rather than lobar consolidation.

3. Mycoplasma pneumoniae is treated with macrolides (e.g., azithromycin).

4. Red flags warranting further evaluation: severe respiratory distress, hypoxia, neurologic signs.

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