Respiratory · Moderate
This case is fictional and exists for study. It describes no real patient.
68 years · male
A 68-year-old male presents to the Emergency Department with a 4-day history of worsening shortness of breath, a productive cough with rust-coloured sputum, and fever. His family reports that he became disoriented and confused earlier this morning. He has a past medical history of essential hypertension managed with amlodipine. On clinical examination, he appears lethargic and mildly tachypnoeic. Chest auscultation reveals dullness to percussion, bronchial breath sounds, and coarse crackles at the right lung base. His Abbreviated Mental Test Score (AMTS) is 6/10, representing new onset confusion.
Vital signs
- HR
- 108 bpm
- BP
- 115/72 mmHg
- RR
- 28/min
- Temp
- 38.7 °C
- SpO₂
- 92%
Examination findings
- Dullness to percussion over the right lower zone
- Bronchial breath sounds and coarse crackles over the right lower lung field
- New disorientation to time and place (AMTS 6/10)
Investigations
| Haemoglobin | 13.8 g/dL | reference: 13.0-17.0 |
| White Blood Cell Count | 17.2 10^9/L | reference: 4.0-11.0 |
| Urea | 8.8 mmol/L | reference: 2.5-7.8 |
| C-reactive protein (CRP) | 185 mg/L | reference: 0-5 |
Question 1 of 3
Based on the clinical presentation and investigation findings, what is this patient's CURB-65 score?
The CURB-65 score assigns 1 point for each of: Confusion (new AMTS <= 8, present = +1), Urea > 7 mmol/L (8.8 mmol/L = +1), Respiratory rate >= 30 (28 = 0), Blood pressure < 90 systolic or <= 60 diastolic (115/72 = 0), and Age >= 65 (68 = +1). Total score = 3 (severe pneumonia). Score 1 and 2 underestimate the score by omitting confusion or urea criteria. Score 4 incorrectly scores the respiratory rate, which is 28 (threshold is >= 30).
Teaching point: CURB-65 scoring requires checking Confusion (AMTS <= 8), Urea > 7 mmol/L, Respiratory rate >= 30, Blood pressure < 90/60, and Age >= 65.
Question 2 of 3
Which of the following is the most appropriate initial imaging investigation to confirm the diagnosis and evaluate for anatomical extent or complications?
A standard posterior-anterior (PA) chest radiograph is the first-line imaging investigation required for all patients with suspected community-acquired pneumonia to confirm lobar consolidation, establish baseline severity, and rule out immediate complications like pleural effusion or empyema. Chest HRCT is reserved for complex, diagnostic dilemmas or non-resolving cases. Thoracic ultrasound is sensitive for pleural fluid and for consolidation that reaches the pleural surface, and is a valuable bedside adjunct, but it is operator-dependent, misses consolidation that does not abut the pleura, and gives no whole-lung overview of anatomical extent. CTPA is indicated for suspected pulmonary embolism, not uncomplicated initial CAP evaluation.
Teaching point: A chest radiograph is mandatory as the initial diagnostic imaging modality for suspected community-acquired pneumonia.
Question 3 of 3
What is the most appropriate initial management strategy for this patient?
Patients with a CURB-65 score of 3 or higher have severe CAP and require urgent hospital admission for parenteral dual antibiotic therapy (e.g., IV co-amoxiclav plus IV/oral clarithromycin according to BTS/NICE guidelines). Outpatient treatment with oral antibiotics (Amoxicillin or Doxycycline) is inappropriate for severe CAP due to high mortality risk. While ICU assessment may be needed if respiratory failure worsens, immediate transfer for invasive ventilation is not indicated as he currently maintains oxygenation without severe respiratory collapse.
Teaching point: Patients with a CURB-65 score >= 3 require urgent hospital admission and empirical treatment for severe pneumonia with dual broad-spectrum antibiotics.
Key learning points
- CURB-65 is a validated clinical prediction rule used to stratify mortality risk and guide management in community-acquired pneumonia.
- A CURB-65 score of 3 or higher indicates severe pneumonia requiring urgent inpatient admission and dual empirical coverage.
- Plain chest radiography remains the gold standard initial imaging tool to confirm pneumonia and screen for complications like parapneumonic effusion.
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