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A 64-Year-Old Woman Comes to the Emergency Department with a 3-Day

question 281

Multiple Choice

A 64-year-old woman comes to the emergency department with a 3-day history of intermittent fever, cough with blood-tinged sputum, night sweats, and generalized malaise. She also reports right-sided chest pain on deep inspiration over the last 24 hours. The patient was diagnosed with breast cancer and is undergoing combination chemotherapy. Her other medical problems include moderate chronic obstructive pulmonary disease and hypothyroidism.
Her temperature is 38.2 C (100.8 F) , blood pressure is 107/64 mm Hg, pulse is 110/min, and respirations are 18/min. Pulse oximetry is 93% on room air. Physical examination is notable for pale conjunctiva. Lung examination shows scattered rhonchi, and cardiac examination is significant for tachycardia without murmurs. The abdomen is soft and nontender without organomegaly. There are no skin rashes.
Laboratory results are as follows:

The patient is started on vancomycin and piperacillin/tazobactam and fails to improve clinically after 3 days of treatment. Computed tomography scan of the chest shows several small (1-2 cm) nodular lesions scattered throughout the lung with surrounding ground-glass attenuation.
Blood and sputum cultures are negative, and bronchoscopy and bronchoalveolar lavage are performed for cultures and cytology.
Which of the following is the best next step in management of this patient?

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Definitions:

Custodial fathers

Fathers who have been granted primary legal and physical custody of their children following a separation or divorce.

Divorced mothers

Women who have legally ended their marriages and are responsible for caring for their children as single parents.

Nontraditional family

A family structure that differs from societal norms, such as single-parent families or families with same-sex parents.

Socioeconomic standing

A composite measure of an individual's or family's economic and social position in relation to others, based on income, education, and occupation.