Shortness of Breath OSCE - Pneumonia

Case Overview

• Age/Sex: 55-year-old male
• Occupation: Office administrator (sedentary job)
• Setting: Emergency Department (walk-in, brought by partner)
• Chief complaint: "I cant catch my breath"

Patient Script

Who I Am

I'm a 55-year-old office worker; I do a lot of sitting at a desk and I smoke about a pack a day.

What Brings Me In

Ive been getting worse breathing for the last day and my partner said I look very pale and are not making sense, so they brought me in.

My Story

About 5 days ago I started with a sore throat and a mild cough. After 4 days it became a cough with thick green sputum and I got a fever. For the last 24 hours my breathing has got a lot worse — Im breathless at rest and I cant lie flat to sleep. Ive had a high temperature (felt hot and shivery) and sweating, and yesterday I spat up a little blood once. Ive felt quite weak and a bit dizzy when I stand up. I havent had chest pain like a heavy crushing pain, but I do get a sharp pain on the right side when I cough.

A couple of months ago I had a bad bout of heartburn that my GP said was reflux. I also went to visit my sister in Spain about 3 weeks ago but felt fine while I was away. I had a urinary infection treated with antibiotics about 10 days ago (finished the tablets). I used to be told I had asthma as a child but I havent needed inhalers since then.

My Medical Background

• Past medical history: childhood asthma (not using inhalers now); no known COPD or heart disease.
• Medications: occasional ibuprofen and paracetamol, completed oral antibiotic for UTI 10 days ago; no prescribed meds.
• Allergies: none known.
• Social: current smoker ~20–30 cigarettes/day (about 30 pack-years); works sitting most of the day; drinks 2-3 units alcohol nightly; lives with partner.
• Family history: father died of heart disease in his 70s; no known lung cancer in family.

What I Think & Worry About

• I think this is probably a chest infection and Im scared Ill stop breathing.
• I worry I might have something serious like pneumonia or a heart attack.
• I want to know if Im going to need to stay in hospital or go to ICU.

If You Ask Me About Other Symptoms...

• Breathlessness: "It started slowly and now Im breathless even at rest, I cant talk in full sentences without stopping to breathe."
• Cough/sputum: "Ive been coughing up green phlegm for days, and once yesterday there was a little blood in it."
• Chest pain: "I have a sharp pain on the right side when I cough or breathe in, not a crushing pain."
• Fever/systemic: "Ive been hot and shivery, Im sweating and feel weak."
• Leg symptoms: "No swelling or pain in my legs." (no DVT symptoms)
• Recent travel/contacts: "I flew to Spain 3 weeks ago but felt fine there; my neighbour had a cold last week." (red herrings)
• Medications/compliance: "I finished a course of antibiotics for a urine infection 10 days ago, I dont take anything else regularly." (red herring)
• Smoking: "I smoke a lot, havent tried to quit recently."

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Clinical Summary

Examination

• General: pale, diaphoretic, appears unwell and breathless at rest, mildly confused (alert but disoriented to time)
• Vital signs: T 39.2C; HR 112 bpm; BP 100/62 mmHg; RR 28/min; SpO2 88% on room air (improves to 94% on 6 L/min via simple face mask)
• HEENT: no jugular venous distension
• Chest inspection: reduced expansion on right lower chest
• Percussion: stony dullness over right lower zone
• Palpation: increased vocal fremitus over right lower zone
• Auscultation: bronchial breath sounds with coarse crackles at right lower lung field; no wheeze
• Cardiovascular: tachycardic, normal heart sounds, no murmurs
• Abdomen: soft, non-tender
• Extremities: no calf swelling; capillary refill <2s

Investigations

• Full blood count: WCC 17.2 x10^9/L (neutrophils 14.8 x10^9/L) (leukocytosis with neutrophilia)
• CRP: 220 mg/L (markedly elevated)
• Urea: 6.0 mmol/L (slightly high-normal)
• Creatinine: 95 µmol/L (baseline unknown)
• Blood lactate: 2.6 mmol/L (elevated, suggests sepsis physiology)
• Arterial blood gas on room air: pH 7.49, PaCO2 30 mmHg, PaO2 55 mmHg, HCO3- 22 mmol/L (hypoxaemia with respiratory alkalosis)
• Chest X-ray (AP upright): dense lobar consolidation of the right lower lobe with small associated pleural effusion
• Blood cultures: sent (pending)
• Sputum sample: sent for Gram stain and culture (pending)
• ECG: sinus tachycardia, no ischemic changes

Diagnosis

• Primary diagnosis: Community-acquired lobar pneumonia (right lower lobe) with hypoxaemic respiratory failure and early sepsis

  • Evidence: acute history of productive cough, fever, pleuritic chest pain; focal signs on chest exam (dullness, increased fremitus, bronchial breath sounds, crackles); CXR showing right lower lobe consolidation; raised WCC and CRP; hypoxaemia on ABG; lactate elevated and tachycardia/hypotension indicating systemic response.

• Differential diagnoses (with reasoning):

  • Pulmonary embolism: acute breathlessness and pleuritic pain could fit, but fever, productive purulent sputum, leukocytosis and focal lobar consolidation on CXR strongly favour pneumonia.
  • Heart failure with pulmonary edema: causes dyspnoea and crackles, but typically bilateral findings, no peripheral oedema, presence of fever and focal consolidation makes pneumonia more likely.
  • Lung cancer with post-obstructive pneumonia: smoker with focal consolidation—consider if poor response to treatment or recurrent infections, but acute high fever and brisk inflammatory markers suggest infectious process rather than primary malignancy currently.
  • Exacerbation of COPD: patient has smoking history but no known COPD diagnosis or baseline wheeze; focal consolidation, fever and raised inflammatory markers favor pneumonia.

Management

• Immediate

  • Administer supplemental oxygen to target SpO2 92–96% (current SpO2 88% on room air; improved on 6 L simple mask)
  • Two sets of blood cultures prior to antibiotics if can be obtained promptly
  • Send sputum for Gram stain and culture
  • Start empirical intravenous antibiotics for severe community-acquired pneumonia (e.g., IV ceftriaxone 1–2 g daily PLUS IV azithromycin 500 mg daily, or local guideline equivalent) as soon as cultures taken
  • Establish IV access and give fluid bolus cautiously if signs of hypoperfusion (e.g., 250-500 mL crystalloid and reassess blood pressure and perfusion)
  • Give paracetamol for fever and IV/SC analgesia for pleuritic pain as needed
  • Consider thromboprophylaxis (LMWH) while admitted

• Monitoring and further care

  • Admit to hospital (medical ward with close monitoring); consider high-dependency/ICU if worsening oxygenation or hemodynamic instability
  • Continuous observation of vital signs, repeat ABG if oxygen requirements increase
  • Review antibiotic choice once culture results available; tailor therapy accordingly
  • If pleural effusion appears moderate/large or if clinically suspected empyema (loculations, persistent fever, purulent fluid), arrange ultrasound and thoracentesis +/- chest drain
  • If poor response to treatment or concern for alternative diagnosis, consider chest CT

Key Learning Points

• Recognize severe community-acquired pneumonia by combination of systemic features (fever, leukocytosis, elevated lactate), focal chest signs and radiographic lobar consolidation; treat promptly with oxygen and empirical IV antibiotics after appropriate cultures.

• Always obtain blood cultures and a sputum sample before starting antibiotics if this will not delay therapy; escalate level of care for hypoxaemia (SpO2 <90% on room air), hypotension, altered mental state or rising lactate.

• Consider but distinguish common mimics: pulmonary embolism and heart failure can present with acute breathlessness and pleuritic pain, but fever, purulent sputum and focal consolidation on exam/CXR point towards pneumonia.