Applying the CURB-65 severity scale (one of the most commonly used in the ED for stratifying the severity of pneumonia, although in this case simply applying common sense, the patient should be admitted to the ICU), we would have a score of at least 4 points (we would be missing the serum urea data), which gives us severity criteria. Since there are no criteria that contraindicate admission to the ICU, admission to the unit would be indicated.

A 72-year-old man presenting since 48 hours with fever of 38.7°C, cough, purulent expectoration and dyspnea. Constants: BP 85/60 mmHg, heart rate 100 bpm, respiratory rate 35 rpm, SatO2 80%. Of note was the presence of confusion and crackles in the left lower lung field. Chest X-ray confirms the existence of pneumonia of the lingula and left lower lobe. What would be the appropriate place of care?

Admission to an emergency observation unit.

Hospital-acquired pneumonia

HAP typically lengthens a hospital stay by 1–2 weeks. Signs and symptoms New or progressive infiltrate on the chest X-ray with one of the following: Fever > 37.8 °C (100 °F) Purulent sputum Leukocytosis > 10,000 cells/μl In an elderly person, the first sign of hospital-acquired pneumonia may be mental changes or confusion. Other symptoms may include: A cough with greenish or pus-like phlegm (sputum) Fever and chills General discomfort, uneasiness, or ill feeling (malaise) Loss of appetite Nausea and vomiting Sharp chest pain that gets worse with deep breathing or coughing Shortness of breath Decreased blood pressure and fast heart rate

Lung Ultrasound for Initial Diagnosis and Subsequent Monitoring of Aspiration Pneumonia in Elderly in Home Medical Care Setting.

The number of aspiration pneumonia cases has increased in recent times. A definitive diagnosis of aspiration pneumonia is difficult in resource-limited settings where radiological equipment is unavailable. We report the initial diagnosis and subsequent monitoring of aspiration pneumonia in a home medical care setting. An 88-year-old Japanese male presented an acute onset of dyspnea, fever, and productive cough. At home, lung ultrasound displayed pleural effusion along with B-lines and subpleural consolidations. Upon admission, tests revealed increased total leucocyte counts with left-shifted neutrophils, elevated C-reactive protein levels, and positive sputum Gram stain. Chest X-ray imaging and computed tomography (CT) showed bibasilar infiltrates and wall thickening in the left S10 bronchi. The patient was diagnosed with aspiration pneumonia and treated with an antibiotic. After a 10-day hospitalization, lung ultrasound showed some remaining B-lines and disappearance of pleural effusion and subpleural consolidation. Chest X-ray image was normal, and CT revealed pleural abnormality and disappearance of bibasilar infiltrates, consistent with the ultrasound findings. Aspiration pneumonia develops with various clinical signs. However, diagnosis using chest X-ray imaging or CT in resource-limited settings is difficult. Ultrasound might allow physicians to make more accurate judgments, particularly while monitoring aspiration pneumonia following initial diagnosis in resource-limited settings.

Dyspnoe, cough and fever in 80-year old patient with chronic heart failure.

The prevalence of heart failure (HF) in developed countries exceeds 10% in adults over 70 year old. At the following report we aim to present a case of HF worsening complicated by gout attack. 80-year old patient was admitted to the hospital, with the suspicion of pneumonia, because of 3-day history of dyspnoe, cough and fever. Patient reported redness, swelling and pain in the area of left elbow. Prior to admission patient was diagnosed with bursitis and treated with antibiotic without symptoms resolution. There was past medical history of atrial fibrillation, hypertension, intermittent claudication, COPD. One month before, patient was hospitalized due to HF worsening. Diuretics' dosage was increased at that time and symptoms resolved. On admission: blood pressure 145/88 mm Hg, HR 96/min irregular, saturation O2 88% without oxygen therapy. On physical examination, bilateral pulmonary crackles, redness, tenderness of left elbow were found. Laboratory tests demonstrated elevated parameters of inflammation - leukocytosis 13.4G/L, neutrophilia 11G/L, CRP 142.5 mg/L, but normal procalcitonin 0.27 ng/ml. Moreover, high NTproBNP 8573 pg/ml and hyperuricemia 13.1 mg/dl were detected. Chest X-ray indicated pulmonary venous congestion. ECG revealed atrial fibrillation with QRS rate of 100/min, left axis deviation. Therefore, gout attack was diagnosed and after colchicine administration symptoms resolved quickly. Clinical signs including fever, elevated parameters of inflammation and dyspnoe justify pneumonia consideration in differential diagnosis. Importantly, non-infectious causes of inflammatory conditions, like gout must be also considered. Patients with HF often develop hyperuricemia due to diuretic treatment, aggravated catabolism and often co-prevalent chronic kidney disease.

Community-acquired pneumonia

Hospitalization Some CAP patients require intensive care, with clinical prediction rules such as the pneumonia severity index and CURB-65 guiding the decision whether or not to hospitalize. Factors increasing the need for hospitalization include: Age greater than 65 Underlying chronic illnesses Respiratory rate greater than 30 per minute Systolic blood pressure less than 90 mmHg Heart rate greater than 125 per minute Temperature below 35 or over 40 °C Confusion Evidence of infection outside the lung Laboratory results indicating hospitalization include: Arterial oxygen tension less than 60 mm Hg Carbon dioxide over 50 mmHg or pH under 7.35 while breathing room air Hematocrit under 30 percent Creatinine over 1.2 mg/dl or blood urea nitrogen over 20 mg/dl White-blood-cell count under 4 × 10^9/L or over 30 × 10^9/L Neutrophil count under 1 x 10^9/L

Jim Henson

Henson was having trouble breathing when he woke up at around 2:00 a.m. (EST) on May 15, 1990, and began coughing up blood. He suggested to his wife that he might be dying, but he did not want to take time off from his schedule to visit a hospital. Two hours later, Henson agreed to be taken by taxi to the emergency room at New York–Presbyterian Hospital in Manhattan. Shortly after admission, he stopped breathing and was rushed into the intensive care unit. X-ray images of his chest revealed multiple abscesses in both of his lungs as a result of a previous bacterial infection. Henson was placed on a ventilator but quickly deteriorated over the next several hours despite increasingly aggressive treatment with multiple antibiotics. Although the medicine killed off most of the infection, it had already weakened many of Henson's organs, and he died at 1:21 a.m. the following morning. He was 53.

Acute bronchitis

A variety of tests may be performed in people presenting with cough and shortness of breath: A chest X-ray is useful to exclude pneumonia which is more common in those with a fever, fast heart rate, fast respiratory rate, or who are old. A sputum sample showing neutrophil granulocytes (inflammatory white blood cells) and culture showing that has pathogenic microorganisms such as Streptococcus species. A blood test would indicate inflammation (as indicated by a raised white blood cell count and elevated C-reactive protein). Decreased breath sounds, crackles, wheezing, and rhonchi that clears with coughs may be heard in the chest. Dullness to percussion and pleural rub suggest disease extension beyond the bronchi such as seen with pneumonia. Paroxysms of cough followed by inspiratory whoop and vomiting suggests pertussis.

Miliary tuberculosis in an immunocompetent male with a fatal outcome.

A man aged 33 years, born in Nepal, but resident in the UK for 7 years presented to the emergency department with a 4-day history of general malaise, fever (temperature 38.6°C) and a non-productive cough. His medical history was unremarkable and no high-risk behaviour was identified. Clinical examination confirmed decreased air entry bilaterally with bibasal crackles. He was tachycardic, with a heart rate of 120 bpm. Further investigation with a 12-lead ECG confirmed supraventricular tachycardia (SVT) which was terminated with vagal manoeuvres. His chest radiograph demonstrated left basal consolidation. His white cell count was 11×10<sup9</sup/L and his C reactive protein was 43.2 mg/L. His blood cultures revealed no growth. He was diagnosed with community-acquired pneumonia and started treatment with amoxicillin and clarithromycin. 3 days post admission, he was intubated for 24 hours in the Department of Intensive Care Medicine. Further episodes of SVT were observed and an ECHO showed a severely dilated and impaired left ventricle. Further chest radiographs illustrated diffuse consolidation with evidence of pulmonary oedema. HIV serology was negative. He developed transaminitis and thrombocytopenia. An ultrasound scan of his liver showed no obvious liver pathology. He remained tachypnoeic and due to worsening pulmonary oedema and extensive consolidation, he was readmitted to the intensive care unit. A CT abdomen with contrast showed an unusual pattern of lymphadenopathy with disproportionately enlarged coeliac axis nodes (5×7×5 cm) and minor para-aortic adenopathy, suspicious for lymphoma. On inserting his central venous catheter in his right internal jugular vein, pus was inadvertently aspirated from his right neck. Acid alcohol fast bacilli (AAFFB) were isolated from the pus and was subsequently identified as Mycobacterium tuberculosis He started treatment with antitubercular medication rifater: a combination of rifampicin 720 mg od, isoniazid 300 mg po od and pyrazinamide 1750 mg. In addition, he received ethambutol 1000 mg po od and pyridoxine 5 mg. He developed worsening metabolic acidosis, pH 7.19, loss of respiratory compensation and pancytopenia. Right heart strain was evident on his Focused Intensive Care Echo. He developed an increased oxygen requirement and respiratory distress on the ventilator. An erect chest radiograph showed bilateral pneumothoraces and bronchopleural fistulae. A chest drain was inserted. Following discussion with the Cardiothoracic Surgeons, pleurodesis was not deemed possible. He developed inotropic-dependent shock with worsening lung compliance. As a result of his deteriorating ventilation, acidosis and hyperkalaemia, he started treatment with continuous veno-venous haemofiltration. With a diagnosis of miliary tuberculosis and SVT causing cardiogenic pulmonary oedema, this man sadly died with his family at his bedside 10 weeks following initial hospital presentation.

[Predictive value of history and physical examination for the diagnosis of community-acquired pneumonia in adults].

Community-acquired pneumonia in adults is a serious health problem in the ambulatory care setting. To define clinical variables associated with the presence of pneumonia in adult patients presenting with fever or respiratory symptoms to the emergency department. Prospective study carried out in the emergency department from the Catholic University Hospital in Santiago, Chile. Three hundred twenty-five patients (53+/-22 years) presenting fever or acute respiratory symptoms were included. After obtaining a clinical history and physical examination, the physician established a tentative diagnosis. Subsequently, a definitive diagnosis was made with the chest X rays. Thirty-four percent of the patients had pneumonia. The clinical diagnosis of pneumonia before X-ray examination was variable among emergency physicians (positive likelihood ratio: 1.5-4.8) and showed only moderate sensitivity (79%) and specificity (66%). The clinical variables significantly associated with the presence of pneumonia were: advanced age (over 75 years), cardiovascular disease, fever, chills, sputum production, orthopnea, altered mental status, cyanosis, dullness on percussion, bronchial breath sounds, crackles, any abnormal vital sign (heart rate>or=100 beats/min, respiratory rate>or=20 breaths/min or temperature>or=38 degrees C) and oxygen saturation below 90% breathing air. Clinical judgment prior to observation of chest X rays had moderate sensitivity and specificity for the diagnosis of pneumonia. There were no individual clinical findings, or combination of findings, that could confirm or exclude the diagnosis of pneumonia for a patient suspected of having this illness.

Clinical and Epidemiological Features of SARS-CoV-2 Patients in SARI Ward of a Tertiary Care Centre in New Delhi.

Rapid spread of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Wuhan, China, prompted heightened surveillance in India. Since the first laboratory confirmed case of SARS-CoV-2 was reported from Kerala on January 30, 2020 novel coronavirus infected pneumonia (NCIP) has been presenting to the hospital emergencies as severe acute respiratory illness (SARI). We aim to find out the rate of SARS-CoV-2 positivity in SARI cases and further clarify the epidemiological and clinical characteristics of NCIP in New Delhi, India. To find out the rate of SARS-CoV-2 positivity in SARI cases presenting to the hospital emergency and describe the epidemiological and clinical characteristics of NCIP. Retrospective, single-center case series of the 82 consecutive hospitalized patients with SARI and subsequent confirmed NCIP cases at Dr Ram Manohar Lohia Hospital, New Delhi between 10th April 2020 and 30th April 2020. Epidemiological, demographic, clinical, laboratory, radiological, and treatment data were collected and analyzed. The primary composite end-point was admission to an intensive care unit (ICU), the use of mechanical ventilation or death. Patients were categorized as severe pneumonia and non-severe pneumonia at time of admission and outcome data was compared. Of the 82 SARI cases, 32(39%) patients were confirmed to be SARS-CoV-2 positive. The median age of NCIP cases was 54.5 years (IQR, 46.25 - 60) and 19(59.3%) of them were males. 24(75%) cases were categorized as severe pneumonia on admission. 22(68.8%) patients had 1 or more co-morbidities. Diabetes mellitus 16(50%), hypertension 11(34.4%) and chronic obstructive airway disease 5(15.6%) were the most common co-existing illnesses. Compared with the patients who did not meet the primary outcome, patients who met the primary outcome were more likely to be having at least 1 underlying comorbidity (p-0.03), diabetes (p-0.003) and hypertension (p-0.03). Common symptoms included dyspnea 29(90.6%) followed by cough 27(84.4%), fever 22(68%), bodyache and myalgias 14(43.75%). Median time from symptom onset to hospital admission was 3 days. The most common pattern on chest X-ray was bilateral patchy nodular or interstitial infiltration seen in 30(93.8%) patients. Leucopenia was present in 10(31.2%) of the patients, with majority of patients presenting with lymphocytopenia, 24(75%) [lymphocyte count (1106 cells/ dL), interquartile range {IQR}, (970-1487)]. Thrombocytopenia was seen in 14(43.8%) patients, pancytopenia in 10(31.2%) patients and anemia was seen in 14(43.8%) patients. Hypoalbuminemia was present in 22(68.8%) cases. Raised CK-MB was seen in 7(21.9%) patients. The primary composite end-point occurred in 12(37.5%) patients, including 9(28.13%) patients who required mechanical ventilation and subsequently expired. 3(9.3%) of these patients who recovered, were subsequently shifted to COVID-19 ward from the ICU. The patients who met the primary outcome were older in age (56.5 years vs 50 years), had significantly higher SOFA scores (6 vs 3.5), were in shock (41.7% vs 5%), in higher respiratory distress (66.7% vs 10%), had lower mean arterial oxygen saturation (85% vs 89.5%), had higher CK-MB values (66 vs 26)U/L [6(54.5%) vs 2(9.5%)], had hypoalbuminemia (100% vs 50%) and acute kidney injury 8(72.7%) vs 5(23.8%) on admission. Of the 50 non-COVID-19 SARI patients in our study cohort, 13 (26%) patients met the primary composite outcome. Of them 9 (18%) patients expired and remaining 4 patients have subsequently recovered. As on 17th May 2020, 23 patients were still hospitalized, recovering in COVID-19 ward. In this single-center case series from New Delhi, out of 82 patients of SARI, 32 patients were confirmed NCIP, with a COVID-19 positivity of 39%. 75% of NCIP presented in severe pneumonia and 37.5% required ICU care. The case fatality rate was 28%.

[Chronic obstructive pulmonary disease in the setting of hospital at home. Study of 522 episodes].

To assess the effectiveness, respiratory status, services of origin and outcome of patient with exacerbated COPD attended in Hospital at Home (HaH) regimen. Study of patients with an exacerbated COPD in HaH from Vitoria-Gasteiz, Spain during the period March 1999-October 2004, in whom hospital admission had been recommended after medical assessment. We studied: age, gender, patient's stay, oxygen-saturation or arterial blood gas analysis, FEV1 (basal), dyspnea status (basal and current), coexisting diseases, exacerbation causes, Services of origin, use of home nebulizers and oxygen therapy, intravenous drugs, course (discharges/admissions/deaths). We analyzed the number of visits to the Emergency Department and hospital admissions 90 days before and after discharge from Hospital at home. A total of 302 patients who generated 522 cases with exacerbated COPD were accepted, 81% of whom are men. Means stay was 11 days (0-111). Three hundred ninety six (76%) of the cases were discharge from HaH, 111 (21%) had to be hospitalized for different reasons, on 13 (2.5%) died. Of these, 43% came from the Respiratory Department and 39% from the Emergency one. Mean FEV1 was 45.4. A total of 89% of the patients had dyspnea 4/4 and 34% 3/4 when seen and 9% of the patients had pneumonia. During the 90 days following discharge from Hospital at Home, the number of visits to the Emergency Department and the rate of hospital admissions decreased significantly (p < 0.001). Our data confirm that Hospital at Home is a good alternative to conventional hospital admission for the management of patients with exaxerbated COPD.

A successful management after preterm delivery in a patient with severe sepsis during third-trimester pregnancy.

A 33-year-old woman visited the emergency department presenting with fever and dyspnea. She was pregnant with gestational age of 31 weeks and 6 days. She had dysuria for 7 days, and fever and dyspnea for 1 day. The vital signs were as follows: blood pressure 110/70 mmHg, heart rate 118 beats/minute, respiratory rate 28/minute, body temperature 38.7℃, and oxygen saturation by pulse oximetry 84% during inhalation of 5 liters of oxygen by nasal prongs. Crackles were heard over both lung fields. There were no signs of uterine contractions. Chest X-ray and chest computed tomography scan showed multiple consolidations and air bronchograms in both lungs. According to urinalysis, there was pyuria and microscopic hematuria. She was diagnosed with community-acquired pneumonia and urinary tract infection (UTI) that progressed to severe sepsis and acute respiratory failure. We found extended-spectrum beta-lactamase producing <iEscherichia coli</i in the blood culture and methicillin-resistant Staphylococcus aureus in the sputum culture. The patient was transferred to the intensive care unit with administration of antibiotics and supplementation of high-flow oxygen. On hospital day 2, hypoxemia was aggravated. She underwent endotracheal intubation and mechanical ventilation. After 3 hours, fetal distress was suspected. Under 100% fraction of inspired oxygen, her oxygen partial pressure was 87 mmHg in the arterial blood. She developed acute kidney injury and thrombocytopenia. We diagnosed her with multi-organ failure due to severe sepsis. After an emergent cesarean section, pneumonia, UTI, and other organ failures gradually recovered. The patient and baby were discharged soon thereafter.

The admission of patients with pneumonia directly from the Emergency Department to Hospital in the Home.

Acute respiratory infection is often the commonest reason for patients to be admitted to hospital from the Emergency Department (ED). Hospital in the Home Units (HHUs) deliver acute hospital type care to patients at home. This study sought to review the safety and effectiveness of HHU care for patients with pneumonia referred directly from an ED to a HHU using standard selection criteria. A retrospective clinical audit of all patients with acute pneumonia referred from the ED to the HHU from March 2000 to March 2002. 45 episodes in 44 patients were identified. 19 patients were female and the mean age was 53 years. Seven (15.6%) patients were residents of nursing homes.In 23 (51.1%) episodes, patients had presented to ED already taking oral antibiotics for their current condition. In 30 patients, significant co-morbidities were identified.The mean temperature on presentation was 37.7° Centigrade. The range of oxygen saturation was 89-100%, with a mean of 95%. Positive chest xray findings were reported in 41 (91.1%) of 45 episodes. In 9 (20%) cases an effusion was also reported.Length of stay ranged from 1-20 days with a mean of 6.2 days. In all 45 episodes, patients were treated with ceftriaxone. Adjuvant oral therapy was initiated in 28 episodes. Other adjuvant therapy was initiated at admission: nebulised salbutamol (7); oral prednisolone (1).Intravenous crystalloid fluids were required at home for rehydration in 2 episodes. Antibiotic therapy was altered in two cases. Oral prednisolone was commenced in 4 episodes, nebulised salbutamol commenced in 7 episodes, and fluconazole and frusemide were each commenced in a single episode.In three cases the primary discharge diagnosis was not related to respiratory infection.In 5 episodes (11.1%), patients made an unplanned telephone call to HHU staff. In 4 (8.9%) episodes, an unplanned staff visit was required. One patient required a return to hospital to complete her inpatient treatment. Two patients were readmitted within 1 month of discharge from EHHU. Patients who present to EDs with respiratory infection requiring intravenous therapy may be safely referred directly into Hospital in the Home care.

A 24-Year-Old Man With Dyspnea and a Broken Left Femur.

A 24-year-old White man presented with 1-day complaints of progressive shortness of breath and fever. He recently underwent an open reduction and internal fixation of a left midshaft femur fracture from a skiing accident 4 days ago. He denied chest pain, skin rashes, hemoptysis, hematemesis, melena, or surgical site bleeding. On arrival, the patient appeared in mild respiratory distress with a respiratory rate of 23 breaths/min, temperature of 37.8°C, heart rate of 97 beats/min, BP of 95/54 mm Hg, and peripheral saturation of 97% on 6-L/min nasal canula. His initial peripheral saturation on room air was 67%. Physical examination was unremarkable, except for diffuse rhonchi on chest auscultation. Chest radiograph on admission showed alveolar opacities predominantly in bilateral lower lobes. A chest CT angiography revealed no evidence for pulmonary embolism. However, there were findings of diffuse bilateral ground-glass opacities with areas of patchy consolidation and innumerous micronodules in both lungs (Fig 1). Laboratory examination was significant for a drop of hemoglobin by 3 g/dL and hematocrit level by 7% since his hospital discharge 4 days earlier. His renal function and urine analysis were normal. Venous blood gas on admission showed pH of 7.39 and Pco<sub2</sub of 43 mm Hg. Because of unexplained acute anemia, nonspecific CT chest findings and progressive dyspnea, a bronchoscopy with BAL was performed. Four aliquots of 60 mL saline solution were injected for lavage with fluid return (Fig 2). BAL fluid showed WBC count of 0.411 × 10<sup3</sup/mm<sup3</sup, RBC count of 318 × 10<sup3</sup/mm<sup3</sup, 100% fresh RBCs, 73% neutrophil, 24% lymphocytes, 1% monocytes, and 2% eosinophils. BAL fluid cytologic condition is shown in Figure 3. A full vasculitis workup by rheumatology was unremarkable. Ophthalmologic and skin examination were unrevealing.

Diagnostic value of lung auscultation in an emergency room setting.

In daily routine, physicians use history, physical examination and technology-based information such as laboratory tests and imaging studies to diagnose the patients' disease. We determined the diagnostic value of lung auscultation in patients admitted to the Medical emergency room with chest symptoms. Two-hundred-and forty-three consecutive patients (137 males), mean age 59.2 years were included. Internal Medicine registrars had to make a presumptive diagnosis, 1) after having taken the history and 2) after having auscultated the lungs. Thereafter, routine diagnostic procedures were performed. The estimated diagnosis was compared with the final diagnosis based on the written report to the Family Practitioner. Two-hundred-eighty-seven diagnoses were made. Eighteen percent of patients suffered from left heart failure, 13% from unexplained chest pain, 10.5% from chest wall pain, and 10.5% from pneumonia. Forty-one percent of the diagnoses were already correct when based only on the patient's history. Lung auscultation improved the diagnostic yield only in 1% and worsened it in another 3%. By multiple logistic regression, normal lung auscultation (OR 0.12 [95CI% 0.053-0.29]) was the independent predictor for not having a lung or heart disease. However, elevation of B-type natiuretic peptide (BNP) (OR 1.16 per 100 pg/ml (95CI% 1.004-1.35), wheezing (OR 0.023 [0.002-0.33]) and pCO2 (OR 0.25 (0.10-0.621) were independent predictors for having a heart disease, whereas wheezing (OR 7.41 [3.26-16.83]) and CRP (OR 1.008 per 10 units [1.003-1.014]) were risk factors for having a lung disease. In contrast to history taking, abnormal lung auscultation does not appear to contribute considerably to the final diagnosis in patients presenting with chest symptoms in an emergency room setting. However, normal lung auscultation is a valuable predictor for not having a lung or heart disease, whereas wheezing is a predictor for having a lung disease and not having a heart disease.

Community-acquired pneumonia

X-ray findings indicating hospitalization include: Involvement of more than one lobe of the lung Presence of a cavity Pleural effusion Prognosis The CAP outpatient mortality rate is less than one percent, with fever typically responding within the first two days of therapy, and other symptoms abating in the first week. However, X-rays may remain abnormal for at least a month. Hospitalized patients have an average mortality rate of 12 percent, with the rate rising to 40 percent for patients with bloodstream infections or those who require intensive care. Factors increasing mortality are identical to those indicating hospitalization.

Enterococcus faecalis-associated lung abscess in a male adolescent- a case report.

Enterococci are rarely considered pulmonary pathogens; they are usually regarded as colonizers of the airway. The authors present the case of a previously healthy male adolescent, with complaints of fatigue and chest pain, who was diagnosed with Enterococcus faecalis-associated acute primary lung abscess. A previously healthy 17-year old boy was admitted to the pediatric ward due to a one-week history of fatigue, inspiratory left side chest pain, dry cough and nasal obstruction. On admission at the emergency department, he was afebrile, with no signs of respiratory distress, but with diminished breath sounds on the left side. A chest x-ray showed a round opacity on the posterior basal segment of the left lower lobe; he was discharged with oral amoxicillin 1000 mg three times a day with the diagnosis of community-acquired pneumonia. Due to the worsening of the productive cough with purulent stinking sputum he was re-evaluated after 4 days. Laboratory studies showed a leukocyte count of 15200/uL and a c-reactive protein of 172 mg/l. The chest computed tomography scan was suggestive of a consolidation of the left lower lobe base and a central abscess. An intravenous course of ceftriaxone and clindamycin was initiated, with a favourable clinical evolution. The bronchofibroscopy performed on day four after his admission revealed the presence of a tracheal bronchus and numerous purulent secretions. Culture examination of bronchoalveolar lavage fluid samples was positive (> 10^5) for Enterococcus faecalis. No complications were registered during his stay in the pediatric ward. He was discharged after a 14-day course of intravenous ceftriaxone and clindamycin, with the recommendation to complete a four-week course of oral amoxicillin/clavulanic acid. On his reevaluation 4 weeks after his discharge, he was asymptomatic. This case report highlights the importance of considering Enterococcus faecalis as an etiologic agent in cases of non-resolving or complicated cases of pneumonia, such as lung abscesses, even in young patients with no comorbidities or risk factors.

Hospital at home for acute exacerbations of chronic obstructive pulmonary disease.

Hospital at home schemes are a recently adopted method of service delivery for the management of acute exacerbations of chronic obstructive pulmonary disease (COPD) aimed at reducing demand for acute hospital inpatient beds and promoting a patient-centred approach through admission avoidance. However, evidence in support of such a service is contradictory. To evaluate the efficacy of hospital at home compared to hospital inpatient care in acute exacerbations of COPD. Trials were identified from searches of electronic databases, including CENTRAL, MEDLINE, EMBASE, and the Cochrane Airways Group Register (CAGR). The review authors checked the reference lists of included trials. The CAGR was searched up to February 2012. The additional databases were searched up to October 2010. We considered randomised controlled trials where patients presented to the emergency department with an exacerbation of their COPD. Studies must not have recruited patients for whom treatment at home is usually not viewed as an responsible option (e.g. patients with an impaired level of consciousness, acute confusion, acute changes on the radiograph or electrocardiogram, arterial pH less than 7.35, concomitant medical conditions). Two review authors independently selected articles for inclusion, assessed the risk of bias and extracted data for each of the included trials. Eight trials with 870 patients were included in the review and showed a significant reduction in readmission rates for hospital at home compared with hospital inpatient care of acute exacerbations of COPD (risk ratio (RR)0.76; 95% confidence interval (CI) from 0.59 to 0.99; P=0.04). Moreover, we observed a trend towards lower mortality in the hospital at home group, but the pooled effect estimate did not reach statistical significance (RR 0.65, 95% CI 0.40 to 1.04, P = 0.07). For health-related quality of life, lung function (FEV1) and direct costs, the quality of the available evidence is in general too weak to make firm conclusions. Selected patients presenting to hospital emergency departments with acute exacerbations of COPD can be safely and successfully treated at home with support from respiratory nurses. We found evidence of moderate quality that hospital at home may be advantageous with respect to readmission rates in these patients. Treatment of acute exacerbation of COPD in hospital at home also show a trend towards reduced mortality rate when compared with conventional inpatient treatment, but these results did not reach statistical significance (moderate quality evidence). For other outcomes than readmission and mortality rate, we assessed the evidence to be of low or very low quality.

What is the role of Ewingella americana in humans? A case report in a healthy 4-year-old girl.

Ewingella americana (Ea) is a Gram-negative, lactose-fermenting, oxidase-negative and catalase-positive bacterium that was first described in 1983 as a new genus and species in the family Enterobacteriaceae. It is not known whether Ea is a true pathogen or simply an opportunistic infectious agent, as most of the cases have been described in patients at risk. A 4-year-old girl described here was hospitalized due to a productive cough over the previous 3 weeks and a fever > 38 °C associated with tachypnea over the previous 2 days. Her familial and personal medical histories were negative for relevant diseases, including respiratory infections. At admission, she was febrile (axillary temperature 39.2 °C) and had dyspnea with retractions, grunting and nasal flaring. A chest examination revealed fine crackling rales in the left upper field associated with bilateral wheezing. A chest X-ray revealed segmental consolidation of the lingula of the left lung. Laboratory tests revealed leukocytosis (15.,800 white blood cells/mm<sup3</sup with 50.3% neutrophils), a slight increase in serum C-reactive protein (11.9 mg/L) and normal procalcitonin values (< 0.12 ng/mL). A nasopharyngeal swab culture did not reveal viral or bacterial respiratory pathogens, including atypical bacteria. A blood culture revealed the presence of a Gram-negative, lactose-fermenting rod that was oxidase negative and catalase positive. The isolate was identified by means of the VITEK®2 identification system (bioMérieux, Firenze, Italy) as Ea. This identification was confirmed by sequencing the 16 s ribosomal deoxyribonucleic acid (rDNA). The pathogen was sensitive to aminoglycoside, fluoroquinolones, carbapenems, cefotaxime, and ceftazidime but was intermediate against sulfametoxazole/trimethoprim and resistant to amoxicillin-clavulanic acid, fosfomycin, and oxacillin. The child was immediately treated orally with amoxicillin-clavulanic acid and erythromycin. Based on the results of a blood culture and sensitivity tests, the amoxicillin-clavulanic acid medication was stopped after 3 days. Erythromycin was continued for a total of 10 days, and the child was discharged after 3 days in the hospital. Follow-up visit 1 month later did not reveal any respiratory problems. This case shows that Ea infections in healthy subjects are mild even in pediatric age, and the need for antibiotic therapy is debated. Cases occurring in subjects with underlying chronic disease can be significantly more complicated and require appropriate antibiotic therapy.

[Amoxicillin as a 1st choice: 275 acute focal pneumopathies treated on an outpatient basis].

From December 1986 to January 1988, 100 General Practitioners and Pneumologists working outside hospital included in open unmatched series 275 patients who were diagnosed as having pneumonia at home. The study consisted of 53.2% men with an average age of 49.3 plus or minus 19.3. Their temperature on the first day (J1) was in 72.7% of cases greater than 38.5 degrees Centigrade. The doctors felt that the general state was good in 66.5% of the cases. Cough was present in 83.5% of cases but was dry in one out of every two. The patients received Amoxycillin in a dose of 2 grams per day orally (66.9%), or by injection (33.1%). On the third day (J3) 90% of the patients had a temperature below 38.5 degrees Centigrade. Their general state was improved in 94.6% of cases. The diagnosis of pneumonia at home was confirmed radiologically on 219 of the films available, confirming the good specificity of the clinical diagnosis of pneumonia at home. Ten patients were hospitalised. The apparent treatment of Amoxycillin was given in 247 cases (89.8% of cases). In 28 cases (10.2%) the treatment was changed by the addition or substitution of a Macrolide (15), or another antibiotic (5), and in 80 cases a change of treatment was not specified. 25 of these 28 cases were reviewed on the 14th day (J14) and no failures were observed after the change of treatment. In 247 patients in whom the treatment with Amoxycillin was followed 336 were reviewed on the 15th day and there had been four failures. Three were intolerant to the drug and there was one relapse.(ABSTRACT TRUNCATED AT 250 WORDS)

Helmet-based noninvasive ventilation for acute exacerbation of chronic obstructive pulmonary disease: A case report.

Noninvasive ventilation (NIV) reduces intubation rates, mortalities, and lengths of hospital and intensive care unit stays in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Helmet-based NIV is better tolerated than oronasal mask-based ventilation, and thus, allows NIV to be conducted for prolonged periods at higher pressures with minimal air leaks. A 73-year-old man with a previous diagnosis of COPD stage 4 was admitted to our medical intensive care unit with chief complaints of cough, sputum, and dyspnea of several days' duration. For 10 mo, he had been on oxygen at home by day and had used an oronasal mask-based NIV at night. At intensive care unit admission, he breathed using respiratory accessory muscles. Hypercapnia and signs of infection were detected, and infiltration was observed in the right lower lung field by chest radiography. Thus, we diagnosed AECOPD by community-acquired pneumonia. After admission, respiratory distress steadily deteriorated and invasive mechanical ventilation became necessary. However, the patient refused this option, and thus, we selected helmet-based NIV as a salvage treatment. After 3 d of helmet-based NIV, his consciousness level and hypercapnia recovered to his pre-hospitalization level. Helmet-based NIV could be considered as a salvage treatment when AECOPD patients refuse invasive mechanical ventilation and oronasal mask-based NIV is ineffective.

Outpatient diagnosis of acute chest pain in adults.

Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.

<i>Pneumocystis jiroveci</i> pneumonia in a patient taking Benepali for rheumatoid arthritis.

We present a case of a 57-year-old woman who contracted <iPneumocystis jiroveci</i pneumonia while on Benepali, the biosimilar version of etanercept for rheumatoid arthritis. She had seropositive erosive disease. She was admitted to clinic with a 2-week history of dyspnoea, dry cough and fever. Her initial examination showed her to be hypoxic on air with saturations of 77% and left basal crackles. Her admission chest X-ray showed fine reticular shadowing, with an initial suspicion of pulmonary fibrosis. She was empirically treated for community-acquired pneumonia but continued to deteriorate with a worsening type 1 respiratory failure. She was intubated and ventilated on intensive care. The suspicion was raised of <iP. jiroveci</i pneumonia given her immunosuppression, hypoxic presentation and chest X-ray changes. This was confirmed on sputum PCR. She was treated with a 3-week course of steroids and co-trimoxazole. She was discharged home after a 2-week admission.

Hospital admission decision for patients with community-acquired pneumonia: variability among physicians in an emergency department.

We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes. We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics. Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions. We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.

[Fulminant Mycoplasma pneumoniae pneumonia resulting in respiratory failure and a prolonged pulmonary lesion].

A previously healthy 26-year-old woman presented with a fever and coughing on October 1, 1995. Despite treatment with beta-lactam antibiotics at another hospital, she had a high fever, coughing, and dyspnea. A chest roentgenogram showed diffuse infiltrates in both lung fields. On October 9, she was transferred to our hospital. On admission, a chest X-ray film showed marked diffusely infiltrates in both lung fields and a effusion in the left lung. Arterial blood gas analysis after inhalation of 4 liters per minute of oxygen via a nasal cannula revealed a PaO2 of 39.0 torr. Despite treatment with various antibiotics, including minocyclin and gamma-globulin, her respiratory condition rapidly deteriorated. She was mechanically ventilated by with intermittent mandatory ventilation and positive end-experiatory pressure, and received antibiotics and methylprednisolone pulse therapy. He chest X-ray and arterial blood gase findings, gradually improved. The passive hemagglutination titer for Mycoplasma rose from 1:4 on October 9, to 1:2,560 on the 14th hospital day. Acute respiratory failure due to Mycoplasma pneumoniae pneumonia was diagnosed. A chest X-ray film obtained 2 months after admission showed linear-reticular shadows in both lung fields and pulmonary-function tests revealed abnormally low vital capacity and diffusing capacity. Examination of a specimen obtained by transbronchial lung biopsy revealed focal intraalveolar exudate with fibrin and macrophages. Very mild interstitial thickening was also noted. The lymphocyte stimulation responses to PPD, PHA, and Con A were low early in the illness and became normal after recovery. Several reports have said that an enhanced pulmonary cellular immune response may be responsible for the development of severe Mycoplasma pneumoniae, resulting in a temporary decrease in the cell-mediated immune response. This case supports that hypothesis. We believe that in severe cases, steroid therapy including pulse therapy should be started as soon as possible.

Use of antibiotics in patients admitted to the hospital due to acute exacerbation of chronic obstructive pulmonary disease (COPD).

BACKGROUND: The purpose of this study was to assess to what extent symptoms and signs of bacterial infection are present and evaluated in patients admitted to the hospital for exacerbation of chronic obstructive pulmonary disease (COPD) in relation to initiation of antibiotic treatment. METHODS: All adult patients (>18 years of age) discharged from a department of internal medicine in Copenhagen in 1997 with a diagnosis of exacerbation of COPD were included in our study and their reports were retrospectively reviewed. Gender, age, number of admissions and length of hospital stay, use of antibiotics and steroids prior to admission, temperature, white blood cell (WBC) count, results of lung auscultation and X-ray examination of the thorax at admittance, and growth of sputum culture and antibiotic treatment in the hospital were all registered. RESULTS: A total of 400 admissions took place. In 104 of them, chest X-ray was compatible with pneumonia, and 99 cases were treated with antibiotics. In 44% of the remaining 296 cases, antibiotics were given. It was found that 25-45% of the patients with very little evidence of infection-i.e. the absence of, or only the presence of, one of the following indicators of infection: fever (temperature>37.5 degrees C), a raised WBC count (>9 billion/l), or crepitation at lung auscultation-were given antibiotics. In cases presenting with two or three of these indicators, 50-75% were given antibiotics. In 85% of the cases, penicillin or a macrolide was the initial antibiotic of choice. The median hospital stay was 6 days for the entire group of patients. CONCLUSION: These data suggest that, in patients with acute exacerbation of COPD, a relatively high number of patients with only weak symptoms or signs of bacterial infection are treated with antibiotics.

Cases from the medical grand rounds of the Osler Medical Service at Johns Hopkins University.

A 77-year-old man was in good health until he complained of fatigue 3 weeks before presentation. Two weeks before admission, he developed gradually worsening shortness of breath. One week before admission, he developed a cough that initially was nonproductive but later was associated with hemoptysis.His past medical history was remarkable for a history of colon cancer (Dukes' stage III), for which he underwent a hemicolectomy and treatment with adjuvant chemotherapy in 1993. He had a myocardial infarction in 1986 and underwent coronary artery bypass surgery in 1999. He also had a history of hypertension, type 2 diabetes, and gout. He smoked in the past but had stopped more than 30 years ago.He was initially evaluated by his primary care physician, who noted that he complained of diaphoresis but denied fevers, chills, or contact with others who were ill. His physical examination was remarkable for bilateral crackles that were more pronounced on the right. A chest radiograph demonstrated bilateral pulmonary infiltrates (Figure 1). He was treated with amoxicillin. The next day, however, his physician noted that his dyspnea had worsened and that his oxygen saturation on room air was poor. He was therefore admitted for further evaluation. The amoxicillin was discontinued, and he was treated with levofloxacin, followed by ceftriaxone and azithromycin as his pulmonary status continued to deteriorate. He received intravenous diuretic agents, which failed to improve his respiratory status. During the initial phase of hospitalization, he was anemic, with a hematocrit of 21.3%. His serum creatinine level, which had been 1.0 mg/dL in 1999, was now 2.5 mg/dL. Urinalysis was remarkable for the presence of numerous red blood cells. His oxygen requirement increased, and he eventually required a 100% nonrebreather mask. A computed tomographic scan of the chest demonstrated prominent alveolar opacities throughout the right upper, middle, and lower lobes, with similar opacities in the left upper and left lower lobes (Figure 2). An echocardiogram showed an ejection fraction of 50%, as well as mild mitral regurgitation. Serologies were remarkable for an antinuclear antibody titer of 1:320 and a P-antineutrophil cytoplasmic antibody (P-ANCA) titer of greater than 1:320. C-ANCA was negative. Anti-glomerular basement membrane and anti-human immunodeficiency virus antibodies were undetectable.

[Clinical and radiological diagnosis of community-acquired pneumonia in adults].

Community acquired pneumonia in adults is an acute disease characterized by worsening in general conditions, fever, chills, cough, mucopurulent sputum and dyspnea; associated with tachycardia, tachypnea, fever and focal signs in pulmonary examination. The probability of pneumonia in a patient with acute respiratory symptoms depends on the disease prevalence in the environment where it is acquired and on clinical features. It is estimated that pneumonia prevalence is 3-5% in patients with respiratory disease seen in outpatient facilities. Clinical diagnosis of pneumonia without radiological confirmation lacks specificity because clinical presentation (history and physical examination) does not allow to differentiate pneumonia from other acute respiratory diseases (upper respiratory infections, bronchitis, influenza). Diagnosis must be based in clinical-radiological findings: clinical history and physical examination suggest the presence of pulmonary infection but accurate diagnosis is established when chest X ray confirms the existence of pulmonary infiltrates. Clinical findings and chest X ray do not permit to predict with certainty the etiology of pulmonary infection. Radiology is useful to confirm clinical suspicion, it establishes pneumonia location, its extension and severity; furthermore, it allows differentiation between pneumonia and other diseases, to detect possible complications, and may be useful in follow up of high risk patients. The resolution of radiological infiltrates often ensues several weeks or months after clinical recovery, especially in the elderly and in multilobar pneumonia cared for in intensive care units.

[Levofloxacin-induced eosinophilic pneumonia complicated by bronchial asthma].

A 76-year-old woman who had complained of cough and productive sputum since mid-January, 1999, was admitted to our hospital with fever and dyspnea on February 4, 1999. She had been treated with levofloxacin at an outpatient clinic. On admission, she had orthopnea, and auscultation revealed coarse crackles and wheeze in the bilateral lung fields. Chest x-ray and CT films showed non-segmental infiltration in bilateral lung fields. Laboratory data revealed eosinophilia in peripheral blood (= 24%) and sputum (= 10%), airflow limitation, hypoxemia (PaO2: 46 Torr), and increased airway responsiveness to methacholine (Dmin: 0.127 units). A bronchoalveolar lavage (BAL) fluid showed increased total cells and a 55% increase in eosinophils, and CD4/CD8 ratio was decreased to 0.8. In addition, IL-5 was increased in BAL fluid. Transbronchial lung biopsy specimens revealed infiltrations of eosinophils in the alveolar and interstitial compartments. Histological features of the bronchial biopsy specimens included increased eosinophils in the submucosa and goblet cell metaplasia. The woman was diagnosed with eosinophilic pneumonia complicated by bronchial asthma. She was given theophylline, pranlukast hydrate, and an inhaled beta 2 receptor agonist (procaterol hydrochloride), and pre-admission drugs including Levofloxacin were discontinued. Her symptoms were improved, peak expiratory flow rate and PaO2 increased, airway responsiveness to methacholine decreased (Dmin: 0.615 units), and radiographic abnormalities disappeared without steroid therapy. A leukocyte migration test for levofloxacin was weakly positive. An environmental provocation test in the patient's home gave negative results. A challenge test for levofloxacin was not performed due to a lack of informed consent. Based on these findings, we diagnosed this case as levofloxacin-induced lung injury manifesting as eosinophilic pneumonia complicated by bronchial asthma. Levofloxacin should be added to the list of agents that can produce eosinophilic pneumonia.

Clinical and Laboratory Findings in Patients With Acute Respiratory Symptoms That Suggest the Necessity of Chest X-ray for Community-Acquired Pneumonia.

Pneumonia is a common illness in all parts of the world and is considered as a major cause of death among all age groups. Nevertheless, only about 5% of patients referring to their primary care physicians with acute respiratory symptoms will develop pneumonia. This study was performed to derive practical criteria for performing chest radiographs for the evaluation of community-acquired pneumonia (CAP). A total of 420 patients with acute respiratory symptoms and positive findings on chest radiograph were evaluated from December 2008 to December 2009. The subjects were referred to outpatient clinics or emergency departments of Birjand's medical university hospitals, Iran, and were enrolled as positive cases. A checklist was completed for each patient including their demographic information, clinical signs and symptoms (cough, sputum production, dyspnea, chest pain, fever, tachycardia, and tachypnea), abnormal findings in pulmonary auscultation and laboratory findings (erythrocyte sedimentation rate, C-reactive protein levels, and white blood cell count). An equal number of age-matched individuals with acute respiratory symptoms, but insignificant findings on chest radiography, were included as the control group. Finally, the diagnostic values of different findings were compared. The data showed that vital signs and physical examination findings are useful screening parameters for predicting chest radiograph findings in outpatient settings. Therefore, by implementing a prediction rule, we would be able to determine which patients would benefit from a chest X-Ray (sensitivity, 94% and specificity, 57%). This study's findings suggest that requesting chest radiographs might not be necessary in patients with acute respiratory symptoms unless the vital signs and/or physical examination findings are abnormal. Considering the 94% sensitivity of this rule for predicting CAP, a chest radiograph is required for patients with unreliable follow-ups or moderate to high likelihood of morbidity if CAP is not initially detected.

Chest pain

Hospital care Hospital care of chest pain begins with initial survey of a person's vital signs, airway and breathing, and level of consciousness. This may also include attachment of ECG leads, cardiac monitors, intravenous lines and other medical devices depending on initial evaluation. After evaluation of a person's history, risk factors, physical examination, laboratory testing and imaging, management begins depending on suspected diagnoses. Depending upon the diagnosis, a person may be placed in the intensive care unit, admitted to the hospital, or be treated outpatient. For persons with suspected cardiac chest pain or acute coronary syndrome, or other emergent diagnoses such as pneumothorax, pulmonary embolism, or aortic dissection, admission to the hospital is most often recommended for further treatment.

<b>S</b>plenic vein thrombosis: rare cause of abdominal pain.

-An 83-year-old woman with a history of hypertension, diabetes and paroxysmal atrial fibrillation anticoagulated with acenocoumarol was brought to the emergency department due to dyspnoea. At admission, the patient reported a 1-week history of malaise, shortness of breath and non-productive cough. She denied fever but reported pain on the left flank. On examination, auscultation showed arrhythmic tones and crackles in the left lower lung field. Laboratory findings showed leucocytosis of 15.32×10<sup3</sup/μL, and the C reactive protein was 177 mg/L. The activated partial thromboplastin time was 54.8 s, and the international normalised ratio was 7.09. A chest X-ray showed left lower lobe consolidation with pleural effusion. Point-of-care ultrasound was performed using a low-frequency curved transducer (2-5 MHz). The probe was placed in the left posterior axillary showing a pulmonary consolidation, but also a hypoechoic lesion in the spleen was found (figure 1).emermed;37/1/30/F1F1F1Figure 1Ultrasound image of the spleen in longitudinal section demonstrating a large, hypoechoic, wedge-shaped lesion. QUESTION: What is the most likely diagnosis?Splenic abscessSubcapsular splenic haematomaSplenic infarctionSplenic hydatid cyst <iFor answer see page 2</i.

[Critical evaluation and predictive value of clinical presentation in out-patients with acute community-acquired pneumonia].

Diagnostic probability of community-acquired pneumonia (CAP) depends on data related to age and clinical and radiological findings. The critical evaluation of data in the literature leads to the following conclusions: 1) the prevalence of CAP in a given population with acute respiratory disease is 5% in outpatients and 10% in an emergency care unit. This could be as low as 2% in young people and even higher than 40% in hospitalized elderly patients; 2) the collection of clinical data is linked to the way the patient is examined and to the expertise of the clinician. The absolute lack of "vital signs" has a good negative predictive value in CAP; presence of unilateral crackles has a good positive predictive value; 3) there is a wide range of X-ray abnormalities: localized alveolar opacities; interstitial opacities, limited of diffused. The greatest radiological difficulties are encountered in old people with disorders including chronic respiratory or cardiac opacities and as a consequence of the high prevalence of bronchopneumonia episodes at this age; 4) among patients with lower respiratory tract (LRT) infections, the blood levels of leukocytes, CRP and procalcitonine are higher in CAP patients, mainly when their disease has a bacterial origin. Since you have not a threshold value reliably demonstrated in large populations with LRT infections or acute respiratory disease, presence or absence of these parameters could only be taken as a slight hint for a CAP diagnosis.