3a. A patient with fever, cough and left sided chest pain
Case history- A 23 year’s male presents with 5 days high fever with purulent cough and left sided chest pain.
What is the diagnosis striking in your mind?
Community acquired Pneumonia
What key questions would you ask?
- Pattern of fever- remittent fever (Temperature fluctuates more than 20 C but does not touch baseline), single attack of chills and rigor may occur.
- Cough– initially dry, later productive cough with purulent sputum. May be blood stained rusty sputum in pneumococcal pneumonia.
- Chest pain– pleuritic chest pain (stabbing in nature, increased after deep inspiration, coughing and sneezing)
What will you examine?
General examination- Patient is ill looking, temperature is raised and respiratory rate increased.
Chest examination- Features of consolidation (movement reduced on left side, trachea and apex beat in normal position, percussion note woody dull and bronchial breath sound*).
Crepitations may be present in resolution phase of consolidation.
Investigations-
FBC- neutrophilic leucocytosis (WBC>11000 and neutrophil>70%)
X-Ray chest PA view- consolidation (homogenous opacity with air bronchogram)
Sputum for gram- and AFB- staining.
Other investigations such as Blood culture, serological test- not available at primary and secondary level.
Treatment- First assess the severity of pneumonia by using CURB-65 score.
CURB-65 means
Confusion
Urea>7mmol/L
Respiratory rate>30/min
Blood pressure (systolic<90 mmHg or diastolic<60mmHg)
Age>65years
(Score 1 point for each feature)
- Score 3 or more indicates severe pneumonia and needs hospitalization and parenteral therapy.
If score <3, home treatment with
- Maintain fluid balance
- Antibiotic treatment – Prompt administration of antibiotics improves outcome.
- Antibiotic treatment for CAP
- Azithromycin 500 mg daily for 7 days
- Clarithromycin 500 mg 12-hourly orally or
- Erythromycin 500 mg 6-hourly orally
- Analgesic for pleuritic pain- paracetamol, co-codamol or NSAIDs is sufficient.