Skill Checkup: A 19-Year-Old Man With Fever and Productive Cough Associated With Retrosternal Chest Pain

Nathan Bowers, MD, PhD


March 31, 2023

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 19-year-old man in the United States presents with a 3-day history of fever and productive cough associated with retrosternal chest pain. Height and weight are 6 ft (182.88 m) and 145 lb (65.77 kg; body mass index is 19.7), respectively. The patient is a full-time college student and works part-time as a server in a busy restaurant. His medical history is significant for recurrent sinusitis, otitis, and pneumonia since late childhood. The patient does not smoke or engage in recreational drug or alcohol use. Upon presentation, he has a temperature of 101.3 °F (38.5 °C), blood pressure of 120/70 mm Hg, and oxygen saturation of 98%. He does not report a recent history of diarrhea, abdominal pain, or rash. Physical examination reveals nasal congestion and bibasilar rhonchi. Complete blood count (CBC) with differential and comprehensive metabolic panel are within normal ranges. Respiratory pathogens panel comes back negative. Given the patient's history of recurrent respiratory infections, an underlying immunologic disorder is considered, and further testing is ordered. Pertinent findings include immunoglobulin (Ig) A of 52 mg/dL, IgM of 6 mg/dL, and IgG of 89 mg/dL.


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