Information Sheet for Candidates

A 45 year old waiter, John, presents at the

general practice where you work as a locum.
He complains about shortage of breath, irritating
cough and feeling hot and bothered.
Your task is to:
Take a focused history
Examine the patient
Discuss the most likely diagnosis and
possible investigations with the patient
The examiner will provide relevant results
and you the are expected to outline your
management plan for this patient

HOPC:
About 3 days ago John developed flu-like symptoms with a sore throat, headaches, aches
in most joints and a mild temperature. His wife gave him panadol and he stayed at home.
However, since yesterday he feels quite weak, has developed an irritating cough, he was
sweating and had a very high temperature last night.
This morning he vomited several times and produced some clear sputum.
PHx:
John has had no significant illnesses or operations.
SHx:
John is married, 2 children, financially secure, smokes 20 cigarettes / day and drinks
about 6 standard drinks every day. No known allergy.
MEDICATIONS: none
FHx: unremarkable
EXAMINATION:
John looks somewhat flushed and washed out.
VITAL SIGNS: BP 125/75, P 98, RR 26, T 38,6, SaO2 94 on room air.
Coated tongue, dry mucous membranes.
CARDIO-VASCULAR SYSTEM: unremarkable
CHEST: resonant, vesicular breath sounds, small area of crackles and diminished breath
sounds over the right mid zone.
INVESTIGATION:
ABGs:
pH: 7.46, pO2: 70, pCO2: 32, bicarb: 25 mmol/L
UEC:
NAD
FBE:
WCC 14.4 (neutrophilic leucocytosis)
LFT:
NAD
Urinanalysis: + protein, 1+ blood
CXR:
right middle lobe pneumonia
Sputum for micro and culture: not available yet but most common:
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pnuemoniae
(serology!)
Legionella
(serology + urine antigen)
Viral
(serology, naso-pharyngeal aspirate!)
Tuberculosis
Chlamydophila (chlamydia) pneumoniae (serology!)

DIAGNOSIS:
Community Acquired Pneumonia (CAP) = pneumonia occurring
in individuals who are not in hospital and who are not significantly
immunocompromised, usually due to streptococcus pneumoniae.
STRATIFICATION:
PNEUMONIA SEVERITY INDES (PSI):
A risk score based on patient age, coexisting illness, physical signs and results of
investigations can aid management decisions.
Patients with low risk can usually be managed with oral antibiotics at home, while those
at higher risk should be further assessed, and may need admission to hospital and
intravenous therapy or hospital in the home (HITH).
1. Factors that increase risk of community-acquired pneumonia:
Age over 50 years

Immunosuppression

Alcoholism

Indigenous background

Asthma

Institutionalisation

Chronic obstructive pulmonary disease Seizure disorders

Dementia

Smoking

Heart failure

Stroke

2. Patient classification using Pneumonia Severity Index (PSI) 19

PSI risk class I (lowest risk). Patient has none of the following:

Age > 50 years;

History of neoplastic disease, congestive cardiac failure,

cerebrovascular, renal or liver disease; or

Clinical signs altered mental state, pulse rate 125 per

minute, respiratory rate 30 per minute, systolic blood pressure <

90 mmHg, or temperature < 35C or 40C.
PSI risk classes IIV. Patients with any of the above characteristics
are classified according to their PSI score, calculated according to
the table below.

Calculation of PSI risk score

Factor
Patient age
Nursing home resident

PSI score

Age in years (male) or age

10 (female)
+10

Coexisting illnesses
Neoplastic disease
Liver disease
Congestive cardiac failure
Cerebrovascular disease
Renal disease

+30
+20
+10
+10
+10

Signs on examination
Altered mental state
Respiratory rate 30 per
minute
Systolic blood pressure < 90
mmHg
Temperature 35C or 40C
Pulse rate 125 bpm

+20
+20

+20

+15
+10

Results of investigations
Arterial pH < 7.35
Serum urea level 11 mmol/L
Serum sodium level < 130
mmol/L
Serum glucose level 14

+30
+20
+10

+10

mmol/L
Haematocrit < 30%
PO2 < 60 mmHg or O2
saturation < 90%
Pleural effusion

+10
+10

+10

dults*