A 35-year-old woman, mother of 4 young children, presents to urgent care with 7 days of cough, now productive of yellow-green sputum. She reports that 2 of her children were home sick last week with “the flu.” She reports fevers, increasing fatigue, and shortness of breath over the past 2 days. She thought the cough would “go away,” but now her symptoms have worsened.
Her past medical history is unremarkable, except for being a former smoker. Her vital signs are: temperature, 38.5°C; blood pressure, 120/72 mm Hg; heart rate, 112 beats/min; respiratory rate, 24 breaths/min; and O₂ saturation, 92% on room air. She appears ill and coughs frequently. On lung examination, she does not have wheezing but there are focal crackles in the right lower lung field.
Which of the following findings most strongly supports pneumonia rather than acute bronchitis in this patient?
- Focal crackles on lung examination
- Yellow-green sputum
- Duration of cough for 7 days and progressive symptoms
- Fatigue and that her children had been ill
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Correct answer: d. Focal crackles on lung examination
Although she presented with cough and had not been improving over time, focal crackles on lung examination are highly concerning for pneumonia and not typical of acute bronchitis. You remembered that sputum color does not imply bacterial infection or symptom severity. Other signs of pneumonia in this patient included fever, tachycardia, tachypnea, and borderline hypoxia. A chest x-ray would be indicated to evaluate for pneumonia.
Pneumonia was confirmed on x-ray, so the management of this patient included initiating empiric antibiotics, either oral or intravenous therapy based on severity, and supportive care (eg, fluids, antipyretics). You counseled the young mother about the dangers of pneumonia (eg, hypoxia, sepsis, lung effusion) and expressed concern that she might have functional limitations at home taking care of her children and getting the rest and care that she needs. She assured you she would enlist more help at home, follow up with her primary care doctor, and if her symptoms worsened, she would go to the emergency department.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
