CCS Case: Community-Acquired Pneumonia

Case: Community-Acquired Pneumonia

Clinical Setup

• Presentation: 64-year-old male with 3 days of productive cough (rusty sputum), fever 38.8°C, pleuritic chest pain, crackles in the right lower lung field, SpO2 93% on room air.
• Location: Emergency Department (triage to outpatient vs inpatient per severity).

Optimal Order Pathway

1. Immediate Orders (Minute 0–1):
   • Pulse oximetry, continuous cardiac monitoring if hypoxic or tachycardic.
   • IV access, Normal saline 0.9% IV @ 75 mL/hr.
   • Oxygen via nasal cannula if SpO2 < 94%.
2. Focused Exam (Minute 1–2):
   • Lung exam (consolidation signs: crackles, egophony, dullness to percussion), Heart exam.
   • Calculate CURB-65 (Confusion, Urea, Respiratory rate, BP, age ≥ 65) for disposition.
3. Diagnostics (Minute 2–5):
   • CXR PA/lateral (lobar infiltrate confirms diagnosis).
   • CBC, BMP (BUN for CURB-65), blood cultures x2 before antibiotics if inpatient.
   • Sputum Gram stain and culture, fingerstick glucose.
4. Therapeutics (Minute 5–12):
   • Empiric antibiotics promptly:
     • Outpatient (CURB-65 0–1): Amoxicillin-Clavulanate or Doxycycline, OR Azithromycin if low resistance risk.
     • Inpatient non-ICU: Ceftriaxone IV + Azithromycin PO/IV.
     • ICU/severe: Ceftriaxone + Azithromycin ± Vancomycin if MRSA risk.
   • Antipyretics, IV fluids for dehydration, advance clock 30–60 min and re-examine vitals.
5. Disposition (Minute 12–15):
   • CURB-65 0–1, stable vitals, tolerating PO: discharge home with oral antibiotics.
   • CURB-65 ≥ 2, hypoxia, hypotension, or multilobar disease: admit to ward; ICU if respiratory failure or shock.
6. Final 2 Minutes:
   • Counsel on smoking cessation, antibiotic compliance, return precautions (worsening dyspnea, persistent fever > 72 h).
   • Arrange pneumococcal and influenza vaccination; schedule primary care follow-up with repeat CXR in 6–8 weeks (smokers/older adults to rule out malignancy).