Correct!
1. Viral bronchitis
Both the physical examination and chest x-ray are normal. This makes pneumonia and congestive heart failure unlikely. There is no history of COPD which would be unlikely with a 20 pack-year history of smoking. Drug reaction is possible with amiodarone being the most likely cause but is much less common than a respiratory tract infection.
She was asked to return for follow up a week later. She returns with worsening symptoms and was admitted to the hospital.
Laboratory evaluation shows a slightly low hemoglobin 11.6 g/dL and an elevated white blood cell count of 11,100 cells/μL and an elevated neutrophil count (90% neutrophils).
Repeat chest x-ray is show in figure 2.
Figure 2. Repeat chest x-ray on week after the x-ray show in figure 1 showing the PA (Panel A) and lateral (Panel B) views.
A CT scan was performed (Figure 3).
Figure 3. Representative images from the thoracic CT scan.
The patient was started on piperacillin-tazobactam, levofloxacin, and doxycycline. Worsening of cough and pleuritic chest pain were noted. Sputum cultures and smears were negative.
Which of the following is the next step in her evaluation?