Wednesday, December 21, 2022 – 13:59 hours
A call comes from a frantic nurse, and she relates that a 52-year-old lady has presented to the acute-care section of your super clinic. (You’ don’t own the clinic, sure, but you know what we mean). The nurse is animated as the patient “looks unwell with a cough and has chest pain and her temperature is 39.2.” You, of course, don’t get animated yourself because the nurse has already done that–no point two people getting all worked up. Truth is, the nurse is swept off her [good] feet. (BTW: That is a sign of a good nurse. A good nurse acts as a foil, as much as patient advocate. In other words, the nurse makes you look good because he/she is good, but in different ways to you. A bad nurse can also make you look good. But that’s another matter. So, don’t complain about your instruments and certainly don’t complain about the nurses: you can’t lose.)
But it sounds serious enough, so you make up your mind to see this patient in a timely manner–i.e. you make her your priority. She is the next patient you will see.
She’s pale and middle aged and has a nice darker-skinned daughter that makes you wonder after their connection, but only momentarily, because you’re quick to recognise that for what it is when you hear it go a ‘pop’ –just another of your preconceptions going ‘pop’.
In reality, the lady, who looks paler because her daughter’s darker is sitting up talking with enough ease to put you at ease. She’s not diaphoretic. If she’s been broiling a chest infection for 3 weeks, she’s not in shock and not toxic. That’s a good start. You settle back a bit and let her roll out with her story. This first few minutes is when you win a case over. You don’t come in and try to muscle your way in. You stand your ground and let them throw the ball at you.
Cough mostly dry started at least 3 weeks ago, saw her local GP early on during this course for some regular prescriptions and the GP incidentally thought she had a virus and didn’t check her out. (Lesson 1: patients in primary care can come asking after the most mundane of things and actually be sick. When the patient presents, it’s usually for a good reason. Most people are not going to waste their time coming to your clinic, no matter how good looking you are or how super your clinic unless they NEED something.).
She sits up and looks fair in her complexion. She sits up promptly, and with some vigour, so you know that, with a 3-week h/o cough and presenting with high fever she’s not right but neither is it likely that she’s about to collapse in front of you. So you have time to hear her story and examine her and just accept the nurse observations as being true. She is normally quite well, this lady. The nurse notes say: “Unwell.”
The cough started as dry but has become productive. She has chest pressure centrally and also to the upper right (anteriorly). She’s been feeling fatigued of late. (Lesson 2: fatigue and vague pains are a not uncommon presentation of infection/sepsis. If someone has progressive fatiguability, be on guard.) You start to think about examining this lady but she wants to talk and, figuring that if a lady with a chest infection wants to talk that that can’t be all bad. So, you let her. She is lucid, coherent, and really gives a nice account of herself. She also coughs. And you ask a few questions about past (medical) history and meds and any allergies to flesh out the history and put you in a position to act. This lady is almost immediately teary, She is teary from a sense of relief. She is relived not to find the best-looking doctor in the world, but one who would listen. She’s teary because she’s relieved because she can stop worrying knowing that she’s going to live. She knows antibiotics is what she needs. And she came bearing gifts, her good self. And you were good enough to value it.
She’s not in distress. Her chest is clear (but her cough moist and her temperature 39). Her pulse feels strong enough.
That’s enough. Enough in a previously well woman presenting to primary care. Your mind is already made up. Look at her obs. and act.
BP (sitting): 115/72
Pulse: 117
Temperature: 39.5
O2 saturation: 94%.
I know. Where’s the respiratory rate in that? The respiratory rate is one of the first clues to a decompensating patient. But I told you that she’s not in distress, so believe it. If someone’s breathing quickly you’ll know it (you sense it because your mind’s eye registers it and you put that image together with the way the person is talking). Nevertheless, a RR is always nice to know.
You give her ceftriaxone 1g IMI (diluted in 3.5 mL 1% xylocaine). You order a CXR, labs, and a nasopharyngeal swab for resp. viral panel/CoVid/pertussis. Incidentally, moments after her injection she complains of a sharp pain up along her entire right side, as if from the injection itself. It’s likely that she has a predominantly right-sided chest infection and the injection has just brought this pain out into full light. (Lesson 3: almost always just after you intervene, the patient will “invariably,” if only ever so briefly, get “worse.”).
You let her go home on oral doxycycline and Augmentin, with your provisional diagnosis of CAP. She will come back to see you, the good doctor, in two days.
08:41 hours, 30 December 2023
Yesterday, while at work, the results came in.
| X-RAY CHEST History: 52-year-old female with three-week history of productive cough. ? CAP. Findings: Consolidative changes are seen at both lung bases. It is worse at the left base than the right. It is consistent with a bibasal bronchopneumonia. There are no effusions. The heart size is normal. | FULL BLOOD EXAMINATION — Haemoglobin 104 g/L (115-160) Red Cell Count 3.5 x10 ^12 /L (3.6-5.2) Haematocrit 0.32 (0.33-0.46) Mean Cell Volume 93 fL (80-98) Mean Cell Haemoglobin 30 pg (27-35) Platelet Count 400 x10 ^9 /L (150-450) White Cell Count 11.3 x10 ^9 /L (4.0-11.0) Neutrophils 67 % 7.6 x10 ^9 /L (2.0-7.5) Lymphocytes 24 % 2.7 x10 ^9 /L (1.1-4.0) Monocytes 8 % 0.9 x10 ^9 /L (0.2-1.0) Eosinophils 1 % 0.11 x10 ^9 /L (0.04-0.40) Basophils 0 % 0.00 x10 ^9 /L (< 0.21) |
Urea 2.5 mmol/L (2.5-7.5)
Especially, but not only, when it comes to a CXR, always (ALWAYS) look at the images yourself. Do NOT rely on the report only, especially in cases where the report does not match your expectations (the radiologist who reports the films does not get to see and examine the patient). With all due respect to the radiologist, are you going to take the opinion of someone who does not know the patient’s history or have the opportunity to examine them over your own? This is her CXR.
In this case, as is often (but by no means always) the case, the imaging report matches up well with the clinical impression.
See DCBA: A systematic approach to reading a chest X-ray.
Recall, I sent this lady home on oral abx after an IM dose of ceftriaxone.
Was this the right decision?
CURB-65
Clinical prediction rule recommended by the British Thoracic Society that has been validated for predicting mortality in community acquired pneumonia and therefore helps predict inpatient vs outpatient treatment.
Each risk factor scores one point with a maximum score of 5.
- Confusion of new onset
- Urea > 7 mmol/L
- Respiratory rate > 30/min or greater
- Blood pressure
- Age > 65 years
In hindsight, this lady scores 0.
The risk of death at 30 days increases as the CURB-65 score increases: with a mortality of 0.7% for a score of 0 and 3.2% mortality for a score of 1. Based on the following table of survival data, a score of 0-1 can be discharged home.
- 13.0% mortality for a score of 2
- 17.0% mortality for a score of 3
- 41.5% mortality for a score of 4
- 57.0% mortality for a score of 5
SMART-COP
Australian scoring system re: hospitalisation and an ICU admission from a CAP: SMART-COP
Systolic BP < 90 mmHg (2 points)
Multilobe infiltrate (1 point)
Albumin < 35g/L
RR (age adjusted < 50yrs > 25/min, > 50 yrs> 30/min) (1 point)
Tachycardia > 125 bmp (1 point)
Confusion (acute onset) (1 point)
Oxygenation (age adjusted: SpO2 < 93%, PaO2 < 70 mmHg, PF <333 mmHg) (2 points)
pH < 7.35 (2 points)
Scoring:
0 – 2 points: Low risk ( < 2% 30 day mortality)
3 – 4 points: Moderate risk (5- 13% 30 day mortality)
5 – 6 points: High risk (11 – 18% 30 day mortality)
7 or more points: Very high risk (33% 30 day mortality)
In the Australian Community-Acquired Pneumonia Study (ACAPS) cohort, the accuracy for predicting patients who required IRVS (a SMART-COP score of 3 or more points) was a sensitivity of 92%, specificity of 62%.
