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Clinical Opal - Cough and fever

10 August 2023 - Dr Simon Morgan

Jill is a 64-year-old retired accountant who presents to you with her concerned husband, Michael. Jill is usually fit and well apart from a history of well controlled hypertension on perindopril. Jill developed symptoms of a typical cold about four days previously and since then has been unwell with a worsening cough, fever and shortness of breath. She also complains of lower right sided chest pain when she breathes and coughs. She feels ‘exhausted’.

On examination, Jill has a temperature of 38.6, RR 25, BP 130/90, HR 104, O2 sat 91%. She has crackles in her right lung base on auscultation. You suspect community acquired pneumonia (CAP).

Based on Jill’s clinical presentation, should she be admitted to hospital?

Patients with CAP require careful assessment of disease severity to guide appropriate care. Therapeutic Guidelines provides a list of ‘red flag’ features that can help guide whether a patient needs admission to hospital.1 They state that patients with any of the following features need close observation, and are therefore likely to need inpatient care:

  • Tachypnoea (RR>22 breaths/min)
  • Tachycardia (HR>100bpm)
  • Hypotension (sBP<90 mmHg)
  • Acute-onset confusion
  • Hypoxia (O2 saturation<92% on room air)
  • Multilobar involvement on CXR
  • Blood lactate >2mmol/l

Additionally, consideration of comorbidities and the social context of the patient is essential. Ultimately, the decision to admit to hospital should be based on clinical judgement and patient wishes. 

Formal pneumonia severity scoring tools can also be used to assess whether to admit a patient with CAP to hospital. While Therapeutic Guidelines recommends the CRB-65 tool as best suited to assessment in primary care settings, a 2010 meta-analysis found that it may over-predict the probability across all strata of predicted risk and should be used with caution.2

Bacterial infections are a common cause of CAP and the leading cause of Sepsis with mortality rate for those requiring hospitalisation up to 54%.3

Related courses 

This article last reviewed by Susan Helmrich August 2023. 

References

  1. Therapeutic Guidelines https://tgldcdp.tg.org.au/etgAccess
  2. McNally M, et al. Validity of British Thoracic Society guidance (the CRB-65 rule) for predicting the severity of pneumonia in general practice: systematic review and meta-analysis. BJGP 2010; 60 (579)
  3. Cillóniz C, Torres A, Niederman M S. Management of pneumonia in critically ill patients BMJ 2021; 375 :e065871 doi:10.1136/bmj-2021-065871

 

Dr Simon Morgan
Dr Simon Morgan

Simon is a GP based in Newcastle, NSW, and a senior medical educator with Medcast.  He also has medical education roles with the RACGP and GPSA.

Over the past three decades, Simon has worked in clinical and educational roles in NSW and the NT, as well as in the Republic of Ireland. He has published over 75 peer reviewed journal articles, and in 2018 received the RACGP Corliss award for his contribution to medical education.

Simon is passionate about high quality education and training. He has particular interests in GP supervisor professional development and the rational use of tests and medicines. He is a proud member of Doctors for the Environment. He spends his spare time drinking craft beer and pretending that he is a musician in the Euthymics, an all-GP band.

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