Pe

• VS: BP 160/88, P 84, RR 28, T 39.1 °C (102. 4°F), O2 sat 86%, Ht 6 ft, 0 in. (183 cm), Wt 80 kg (176 lb)

• HEENT: Dry mucous membranes

• Chest: Rales and rhonchi R greater than L; diminished breath sounds RML and RLL

• CV: Tachycardic with regular rhythm; normal heart sounds Labs:

• WBC 18.8 x 103/mm3 (18.8 x 109/L), segs 80%, bands 10%, lymphs 10%

• Sputum Gram stain: less than 10 epithelial cells, greater than 25 WBCs, predominance of gram-negative bacilli

CXR: Pulmonary infiltrate right middle and lower lobes of right lung

What findings on physical examination are suggestive of an infectious process?

What laboratory findings and/or diagnostic studies have been performed to help establish the presence of an infection?

Are the findings of these laboratory and diagnostic studies suggestive of an infection? What is your working diagnosis based on this patient encounter?

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