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Stem
A 68-year-old man who smokes 20 cigarettes a day and has type 2 diabetes presents to the emergency department with a 3-day history of fever, a productive cough with rusty sputum, dyspnoea and right-sided pleuritic chest pain. On examination he is confused, his respiratory rate is 32/min, oxygen saturation is 90 percent on room air, blood pressure is 86/52 mmHg, pulse is 112/min and temperature is 38.9 degrees C. Blood tests show urea 9.2 mmol/L, sodium 128 mmol/L, CRP 220 mg/L and a neutrophil leukocytosis. A chest X-ray shows dense right lower-lobe consolidation with a small right pleural effusion.
Questions
a) What is the clinical diagnosis and what is the CURB-65 score? Justify each point. (3 marks)
Diagnosis: severe community-acquired pneumonia (CAP) with early sepsis. CURB-65 = 5. Confusion (new disorientation) — 1; Urea 9.2 mmol/L (over 7) — 1; Respiratory rate 32/min (30 or more) — 1; Blood pressure systolic 86 mmHg (under 90) — 1; age 68 (65 or more) — 1. Hyponatraemia (sodium 128) and GI upset should also raise Legionella, but the dense lobar consolidation and rusty sputum are typical of Streptococcus pneumoniae.
b) Outline the immediate (resuscitation) management in the first hour. (3 marks)
ABCDE; oxygen for hypoxaemia (avoid uncontrolled high-concentration oxygen if COPD is known); measure lactate, take blood cultures before antibiotics if they will not delay the first dose, give IV antibiotics within 1 hour of documented hypotension (beta-lactam plus macrolide), give IV crystalloid for hypotension, and start noradrenaline for fluid-refractory shock. NICE: hospital processes should allow diagnosis and treatment within 4 hours of presentation. Admit to ICU (CURB-65 5; NICE: consider intensive-care assessment at 3 or more). Do not delay antibiotics for imaging.
c) Give the empirical antibiotic regimen with drug, dose, route and rationale, and the likely duration. (3 marks)
ATS/IDSA 2019 severe-CAP empiric cover: a beta-lactam plus a macrolide (for example ceftriaxone 1 to 2 g daily plus azithromycin 500 mg daily or clarithromycin 500 mg twice daily) or a beta-lactam plus a respiratory fluoroquinolone. UK formularies commonly use IV co-amoxiclav plus a macrolide — follow local NICE-aligned policy. Add MRSA or antipseudomonal cover only with locally validated risk factors. Duration: minimum 5 days, stop once temperature 37.8 °C or less for 48 hours and no more than one remaining instability criterion (Uranga 2016).
d) List four complications and one indication to drain the pleural effusion. (1 mark)
Complications: parapneumonic effusion, empyema, lung abscess, sepsis/septic shock, ARDS, new atrial fibrillation. Drain if the effusion is complicated — purulent, size half a hemithorax or more, loculated, pH under 7.20 (or glucose under 60 mg/dL, about 2.2 mmol/L), or positive Gram stain or culture. ATS/IDSA 2019 does not recommend routine follow-up chest imaging once symptoms have resolved within 5 to 7 days; a non-resolving opacity in a smoker still needs a cancer work-up.