A 50-year-old man with a history of alcoholism presents with fever, productive cough, and pleuritic chest pain. On examination, breath sounds are decreased on the right side, and there is dullness to percussion. What is your working diagnosis and next steps?
Given this patient's history of alcoholism and symptoms, aspiration pneumonia leading to a lung abscess or empyema is a concern. Alcoholics are at an increased risk of aspiration, especially while unconscious or semi-conscious. The next steps would include ordering a chest X-ray or chest CT to evaluate for a lung abscess or empyema, as well as blood tests including complete blood count and blood cultures. Broad-spectrum antibiotics covering both aerobic and anaerobic organisms would typically be initiated, and depending on the size and location of the abscess or the presence of empyema, surgical or interventional radiology consultation may be necessary for drainage.