So when thinking about the examination for these patients,
we wanna make sure we listen to the lungs.
The lungs can have lots of different changes.
The classic thing we think about is that the lungs will have rhonchi
which are kind of like a snoring sound,
I always say is sort of what it sounds like.
The other things that can happen now are patients can have wheezing
and this is due to the fact that when there’s a pneumonia there
or possible other infection, or a viral infection,
the airways can become inflamed
and that’s basically what causes the wheezing.
So patients may also have wheezing on exam.
They can have tactile fremitus or egophony.
These are things that we do only occasionally in the emergency department,
but you wanna go ahead because they can also help support or refute
a possible diagnosis of pneumonia.
So you can go ahead and assess for the E to A changes
as well as see if you feel any tactile fremitus.
Other exam findings to think about,
you wanna look and see if your patient has a rash.
There are certain pneumonias or viral processes that can be associated with a rash.
Any patient who comes in with a cough or hemoptysis,
it’s a good idea to do an oropharyngeal exam, take a look in their mouth.
Sometimes also if they’re having upper respiratory symptoms, to look in their ears,
possibly in their nose if you’re worried that that could be a source of bleeding.
And then when thinking about the differential of consequence
and potentially you’re thinking about a pulmonary embolus
or heart failure as a possible cause of the shortness of breath,
you wanna take a look in their legs
and see if they have any evidence of lower extremity swelling or edema.
How are we gonna actually make the diagnosis?
So, we’re gonna definitely think about the patient
and their presenting complaints and their physical exam,
and then we’re gonna wanna move on to diagnostics.
The chest x-ray is gonna be your most important test you’re gonna get here,
and it’s most important because it can be obtained easily,
it can be obtained at the bedside,
and can give you a lot of information as to what’s going on in the patient’s lungs.
We will look at a classic chest x-ray for lobar pneumonia in a moment.
Other testing that can be beneficial are basic blood tests,
so a CBC, a metabolic panel, an EKG,
which can look for any evidence of coronary syndrome or arrhythmias, can help you.
Potentially, this is something that can help if the patient is admitted to the hospital,
a urinary strep or a legionella antigen or a urine test that can be sent
to look for possible strep infection or legionella infection
and strep is a common cause of pneumonia, legionella,
a little bit less common but important to know if that’s what’s going on.
Influenza or other respiratory virus testing,
depending on where you’re practicing and what season it is,
this test may have greater or less availability.
So in the winter months, when influenza and viral illnesses are more common,
this is gonna be much more readily available.
So in addition to influenza, other viruses that sometimes can cause these symptoms
include RSV or rhinovirus and sometimes the testing for that it can help.
Again, if your patient is admitted to the hospital,
you wanna make sure if your patient does have influenza
that they’re not gonna go ahead and give influenza to their neighbor,
to their roommate or to other people in the hospital.
So it has certain implications in those settings as well.
Also, a CT scan of the chest may be beneficial,
especially if your chest x-ray doesn’t show any evidence of pneumonia.
I’ve had lots of patients in whom the chest x-ray has been negative.
Who they’ve gotten a CAT scan over their chest and that CAT scan
has in fact shown pneumonia there that is present.
So while the chest x-ray is a good test,
CT scan can sometimes give you additional information.
Additionally, thinking about that differential of consequence,
if you’re worried about a blood clot in the lungs, a CT scan,
if you do it with IV contrast, can also help take a look for that.
So consider getting a CT scan if you’re concerned about other processes
that could be going on or potentially if your chest x-ray isn’t revealing
and you wanna get a closer look at the lung fields.
We always wanna think about our risk-benefit ratio
when we’re thinking about whether or not to do a CAT scan
because it does expose the patient to radiation.
So always keep that in mind when you’re deciding
whether or not to do this additional testing.
Other things to think about, so should you do blood cultures and pneumonia.
For sure if your patient is septic.
So if they have evidence of sepsis by their vital signs or an elevated lactic acid
or you’re worried about it, blood cultures for sepsis
are generally indicated and can be helpful.
However, for a majority of patients who present with pneumonia,
blood cultures may not necessarily be of benefit
and there are some studies that show that in a very small proportion of patients
who present with pneumonia,
the blood cultures actually change course of management.
You know, that's not to say they won’t be positive,
they very well might be positive but we know generally
what bacteria will be causing a pneumonia,
so generally we can check and do antibiotics
that are gonna cover that specific pneumonia
or cover kind of generally for pneumonia.
So blood cultures don’t always necessarily make a difference
in what we’re doing for these patients.
How about sputum cultures?
Sputum cultures are one thing that actually potentially can change
or make a difference in what you’re doing.
The issue with sputum cultures is that you need to make sure
that you’re getting a sample from in the lungs.
What happens generally when you ask a patient to give a sputum cultures
that they take the cup that you give them and they basically spit in the cup.
You don’t what spit, that’s not gonna help you at all,
you want actually the gunk that’s in their lungs to see what’s in it.
So sometimes if you really want a sputum culture
to kind of get additional information,
you might have to have Respiratory Therapy come
and help you get an induced sputum culture.
So the moral here is, for septic patients, definitely go ahead and do blood cultures.
For other patients with pneumonia, it’s a little bit more debatable
and will depend on the culture of your institution.
Sputum cultures can potentially be of benefit
but you wanna make sure you are getting a good sample.