Patient Evaluation
History
Because of the multiple potential pathogens that cause pneumonia, the history becomes especially important in the evaluation of a patient with pneumonia. Presence or absence of fever, dry or productive cough, acute or gradual onset, and presence of chest pain and dyspnea may help distinguish upper from lower respiratory infection and a ``typical'' from an ``atypical'' pneumonia. In contrast to typical (pneumococcal) pneumonia, atypical pneumonia is characterized by lack of sputum production, lack of chest pain, and radiographic infiltrates that are not evident on physical examination. Agents causing atypical pneumonia are Mycoplasma pneumoniae, Chlamydia pneumoniae, viruses, and Coxiella burnetii. Concomitant medical conditions, recent travel, and animal exposure help to direct evaluation and therapy.
Physical Examination
Attention to all aspects of the physical examination is crucial to determining severity of illness, hospitalization, and possibly treatment. Fever is nonspecific, but a pulse-temperature disparity (normal pulse in the setting of high fever) suggests pneumonia from Mycoplasma, Legionella, Chlamydia, or virus. Tachypnea and cyanosis indicate significant respiratory compromise and thus careful consideration before choosing outpatient vs. inpatient therapy. Examination of the thorax may be unremarkable, reveal evidence of consolidation (dullness to percussion, increased tactile fremitus, egophony), suggest interstitial infiltrates (crackles), or present evidence of a pleural effusion (dullness to percussion, decreased tactile fremitus, decreased breath sounds). Extrapulmonary findings should not be overlooked and can offer clues to the underlying pathogen (Table 73-3). Neurologic disease, altered level of consciousness, and recent seizures suggest aspiration pneumonia. Periodontal disease makes an anaerobic infection more likely.
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