Consolidation

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 02/04/2015

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103 Consolidation

Instruction

Examine this patient’s chest.

Salient features

History

• Abrupt onset of symptoms

• Cough with purulent sputum

• Fever with sweating or rigors

• Pleuritic chest pain (p. 355)

• Shortness of breath

• Haemoptysis

• Nausea, vomiting, diarrhoea (consider legionella infection)

• Mental status changes (especially in the elderly).

Examination

• Purulent sputum (if bacterial in aetiology)

• Tachypnoea

• Reduced movement of the affected side

• Trachea central

• Impaired percussion note

• Bronchial breath sounds

• Crackles.

Diagnosis

This patient has left lower lobe consolidation with purulent sputum (lesion) indicating a bacterial pneumonia (aetiology) and her CURB65 score is zero (functional status).

Questions

What is the aetiology?

• Bacterial pneumonia

• Bronchogenic carcinoma

• Pulmonary infarct.

How would you investigate suspected bacterial pneumonia?

• FBC, serum urea, electrolytes and liver function tests

• Sputum and blood cultures

• Arterial blood gases

• Chest radiography (Fig. 103.1)

• Test for Legionella (culture, direct fluorescent-antibody test or urinary antigen assay), mycoplasma immunoglobulin M

• Consider serological testing for HIV (for patients 15–54 years, particularly when there is lymphopenia or a low CD4 cell count).

image

Fig. 103.1 Air bronchograms in a collapsed and consolidated right lower lobe.

(With permission from Adam et al. 2008.)

Advanced-level questions

How do you determine the severity?

Using the CURB65 severity score, 1 point for each feature present:

• Confusion

• Urea> 7 mmol/l

• Respiratory rate ≥30/min

• BP (systolic <90 mmHg or diastolic ≤60 mmHg)

• Age ≥65 years.

The prognosis based on CURB65 score:

4 or 5: assess with specific consideration to the need for transfer to a critical care unit

≥3: high risk of death

2: moderate risk of death; considered for short-stay inpatient treatment or hospital-supervised outpatient treatment

0 or 1: low risk of death; may be suitable for therapy at home.

The CURB65 severity score should be interpreted in context of the overall clinical picture.

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