Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a several-day history of high-grade fever, non-productive cough, and progressive dyspnea. Associated symptoms include malaise, myalgia, headache, and gastrointestinal distress (diarrhea/nausea). No known recent travel or exposure to aerosolized water sources reported. Symptoms consistent with atypical pneumonia.
Clinical Examination Findings
Vitals: Febrile, tachypneic, hypoxic on room air. HEENT: Moist mucous membranes. Pulmonary: Bilateral crackles/rales, diminished breath sounds at bases. Cardiac: Tachycardia, regular rhythm, no murmurs. Abdominal: Mild epigastric tenderness, bowel sounds present. Neurological: Alert and oriented, mild confusion noted.
Treatment Protocol
Initiate empiric antibiotic therapy with a respiratory fluoroquinolone (e.g., Levofloxacin) or a macrolide (e.g., Azithromycin). Monitor renal function and electrolyte levels (hyponatremia). Provide supplemental oxygen to maintain SpO2 >92%. Supportive care including IV hydration and antipyretics.