Films and Scans
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This chest X-ray is easy to misread if you’re in a hurry. If you step back, there is a hint of volume loss on the left side, particularly at the base. Homing in on this finding, you see that the L diaphragm is obscured, suggesting an isodense process in the lung – potentially either a pneumonia or pulmonary infarct from a PE.
Chest CT clarifies the presence of a L base infiltrate in the retro-cardiac region. These are notoriously difficult to see on a plain CXR, especially the “portable CXR” that one obtains in rapid-fire ED practice. CT shows its virtues here again, by both ruling out a PE and confirming the presence of a pneumonia in the suspicious region on the CXR. Alternatively, a 2-view CXR might give more information at the cost of more time in the ED but less radiation than the CT. As a community-acquired pneumonia, routine treatment is appropriate with a later-generation quinolone or cetriaxone/azithromycin combination.
Note the lack of tachycardia in this patient on beta blockers. Even in the presence of dehydration and infection, beta blockers will do their pharmacologic duty and keep the heart rate from increasing (thereby blocking the appropriate physiologic response). Otherwise, one might tend to under-estimate the detrimental effect of (in this case) the pneumonia on the patient.
Also, consider the work-up of acute delirium (“dad is a little confused”). A strong argument can be made for admission in this case. The consequences of unrecognized delirium if the patient is discharged from the ED include increased ED recidivism (~80% return within 5-days for admission) and increased mortality at 3 months.
Finally, every patient with S.O.B. gets both blood cultures and IV antibiotics up front, lest we fall out of the 6-hour “quality” window for an atypical presentation of pneumonia. Forget the fact that many of these patients don’t end up having pneumonia, and that such practice runs up the cost of medical care and increases antibiotic resistance.
John Dallara, MD, practices emergency medicine in Virginia and North Carolina and directs the EM PREP Course. www.emprepcourse.com