CAP

Question 1

A 35 year old woman presents with a 24 hour history of fever, malaise and cough. She is tachypnoeic with bronchial breath sounds at her right lung base. How would you assess and manage her?

Answer 1

Impression
Given clear sx and sign of respiratory infection, I am provisionally concerned about a community acquired pneumonia in this patient. Is important to consider and determine the underlying aetiology of this infection as it has implications for appropriate management. Given onset, duration and high fevers am thinking more likely a typical vs atypical pneumonia.

Other DDx to consider:
- Infective: COVID, URTI, bronchitis, lung abscess

Goals

• acute stabilisation of patient if required
• thorough Hx/Ex/Ix to inform acute management
• diagnosis with CXR and severity assessment using CURB65
• Manage definitively with ABx and supportive treatment

Question 2

CAP - Assessment

Answer 2

Assessment
A - patent, maintaining, adjuncts unlikely required
B - RR, SP02, auscultation, consider supplemental 02 if sats <94%, CXR at bedside
C - IVC access, HR/BP monitoring. Initial bloods including septic work-up (cultures, VBG, FBC, UEC, LFT, CRP/ESR), empirical ABx administration and fluids, etc. Conduct cardioresp exam, assess for evidence of systemic toxicity
D - GCS
E - exposure, temperate, other sites of infection

Question 3

CAP - History

Answer 3

History

• sx: cough, production, volume, chest pain, dyspnoea, SOB, high fever/chills, malaise, myalgia, lethargy,
• HPI: onset of sx, duration of sx, sick contacts, recent COVID exposure/ RAT test results/PCR test results, work with animals, birds, etc
• RISKS: immunocompromised (meds, diabetes), demographics (old vs young), existing respiratory disease
• SNAP

Question 4

CAP - Examination

Answer 4

Examination

• general appearance + vitals
• Cardioresp exam: breath sounds, consolidation, increased vocal resonance, dullness to percussion
• systems review for systemic illness

Question 5

CAP - Investigations

Answer 5

• Bedside: septic work up, as per A to E assessment, consider UA at bedside and urine MCS. Sputum MCS, nasopharyngeal swab for COVID PCR and other viral infections
• Bloods: as per A to E
• Imaging: CT if CXR is inconclusive

Question 6

CAP - Management

Answer 6

Management
Definitive
- assess severity clinically and with CURB-65 assessment tool/SMART COP, can help guide dispositioning of patient (outpatient vs inpatient, ICU, etc)
- empirical ABx according to eTG (ABC)
o Mild: amoxicillin +/- doxycycline (outpatient)
o Moderate: Benpen +/- doxycycline (inpatient)
o Severe: Ceftriaxone +/- azithromycin (ICU)
- resp review if considering hospital admission

Supportive

• hydration
• electrolyte
• analgesia, antipyretics
• supplemental 02 as required
• Chest physio
• incentive spirometry