BREATHLESS PATIENT68 General Medical Emergencies
(iii) Finally remember tuberculosis, especially in alcoholism or
social deprivation and also in human immunodeficiency virus
(HIV) patients, who may also get Pneumocystis jiroveci (carinii)
pneumonia. See page 153.
2 Risk factors for CAP include: age over 50 years; smoking; coexisting chronic
respiratory, cardiac, renal, cerebrovascular or hepatic disease; diabetes;
alcoholism; neoplasia; nursing home residency; and immunosuppression.
3 Fever, dyspnoea, productive cough, haemoptysis and pleuritic chest pain
may occur.
4 Less obvious presentations include septicaemia with shock, acute confu-
sional state particularly in the elderly, referred upper abdominal pain, or
diarrhoea.
5 Examine for signs of lobar infection, with a dull percussion note and
bronchial breathing. Usually there are only localized moist crepitations with
diminished breath sounds.
6 Send blood for FBC, ELFTs, blood sugar and two sets of blood cultures,
particularly if t here is an intercurrent illness.
(i) Only do an ABG when there are features of severe CAP (see
below).
7 Perform a CXR, which may show diffuse shadowing unless there is lobar
consolidation.
(i) Look at the lateral, particularly for consolidation.
8 Features of severe CAP requiring hospital admission include one or more of
the following:
(i) Respiratory rate ≥30/min.
(ii) Systolic BP <90 mmHg or diastolic BP <60 mmHg.
(iii) Acute onset of confusion.
(iv) Arterial or venous pH <7.35.
(v) Oxygen saturation <92%, or PaO 2 <60 mmHg (below 8 kPa).
(vi) Multilobar CXR changes.
(vii) Urea of >7 mmol/L, or WCC <4 109 /L or >30 109 /L.
9 Predictors of the need for intensive respiratory or vasopressor support
(IRVS) are indicated by the SMART-COP score (see Table 2.6).
(i) A score of 3–4 gives a 1:8 risk of needing IRVS.
(ii) A score of ≥5 indicates severe CAP with a 1:3 risk of needing
IRVS.