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Emergency Medicine Evaluation of Community-Acquired Pneumonia: History, Examination, Imaging and Laboratory Assessment, and Risk Scores

Brit Long, Drew Long, Alex Koyfman
Journal of Emergency Medicine 2017, 53 (5): 642-652

BACKGROUND: Pneumonia is a common infection, accounting for approximately one million hospitalizations in the United States annually. This potentially life-threatening disease is commonly diagnosed based on history, physical examination, and chest radiograph.

OBJECTIVE: To investigate emergency medicine evaluation of community-acquired pneumonia including history, physical examination, imaging, and the use of risk scores in patient assessment.

DISCUSSION: Pneumonia is the number one cause of death from infectious disease. The condition is broken into several categories, the most common being community-acquired pneumonia. Diagnosis centers on history, physical examination, and chest radiograph. However, all are unreliable when used alone, and misdiagnosis occurs in up to one-third of patients. Chest radiograph has a sensitivity of 46-77%, and biomarkers including white blood cell count, procalcitonin, and C-reactive protein provide little benefit in diagnosis. Biomarkers may assist admitting teams, but require further study for use in the emergency department. Ultrasound has shown utility in correctly identifying pneumonia. Clinical gestalt demonstrates greater ability to diagnose pneumonia. Clinical scores including Pneumonia Severity Index (PSI); Confusion, blood Urea nitrogen, Respiratory rate, Blood pressure, age 65 score (CURB-65); and several others may be helpful for disposition, but should supplement, not replace, clinical judgment. Patient socioeconomic status must be considered in disposition decisions.

CONCLUSION: The diagnosis of pneumonia requires clinical gestalt using a combination of history and physical examination. Chest radiograph may be negative, particularly in patients presenting early in disease course and elderly patients. Clinical scores can supplement clinical gestalt and assist in disposition when used appropriately.


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