A 67-year-old female presents to her GP with a four-day history of worsening shortness of breath. This is associated with a cough productive of rust coloured sputum and gradual onset right-sided sharp chest pain that worsens with inspiration. She has a heart rate of 81/min, a respiratory rate of 22/min, a blood pressure of 111/78 and a temperature of 38.3ºC. On examination, there is dullness to percussion, reduced breath sounds and increased vocal resonance on the right side of the chest.

What is the most likely diagnosis?

Options:
explanation: Pneumothorax can present with pleuritic chest pain and shortness of breath. However, they would not present with a productive cough or pyrexia due to a pneumothorax. In addition, they would have hyperresonance to percussion and decreased vocal resonance on auscultation
name: Pneumothorax
label: b
answer: no
explanation: Pericarditis is caused by inflammation of the pericardial lining, typically due to a viral infection. Typical symptoms include pleuritic chest pain (typically worse on laying down and relieved on leaning forward) and fever. A pericardial rub may be heard on auscultation. In this case, this patient has a productive cough, and their pain does not change with posture, making a diagnosis of pneumonia more likely. Their examination findings would also not be present in pericarditis and are better explained by the diagnosis of pneumonia
name: Pericarditis
label: e
answer: no
explanation: Pneumonia typically presents with an acute history of productive cough, breathlessness, chest pain and fever. Other typical features include haemoptysis, septic shock, atrial fibrillation and confusion in the elderly. Rust coloured sputum suggests a _Streptococcus pneumoniae_ infection, which is the most common cause of pneumonia. Dullness to percussion, reduced breath sounds and increased vocal resonance are all typical examination features of pneumonia. The next step in the management of this patient is a CRB-65 score to determine the prognosis and management of this patient. Pneumonia is a radiological diagnosis, so for confirmation of this diagnosis, a patient must have a chest x-ray showing signs of consolidation
name: Pneumonia
label: a
answer: yes
explanation: Pulmonary embolism can present with breathlessness, sudden onset pleuritic chest pain, haemoptysis and the presence of deep vein thrombosis, usually in a patient with other risk factors for pulmonary embolism. It may also present with pyrexia (which is usually mild). Physical examination of the chest is typically normal. As this patient has a history of productive cough, gradual onset pleuritic chest pain, high fever and physical examination suggestive of pneumonia, pneumonia is the more likely diagnosis
name: Pulmonary embolism
label: d
answer: no
explanation: Empyema is a collection of pus within the pleural cavity. This can be a complication following pneumonia, so it can initially present with symptoms of pneumonia. Specific symptoms indicating empyema include fever, chest pain, and breathlessness refractory to antibiotic treatment for pneumonia. Examination findings are similar to pleural effusion, including reduced breath sounds, dullness to percussion and reduced vocal resonance. The presence of productive cough and increased vocal resonance makes a diagnosis of pneumonia more likely
name: Empyema
label: c
answer: no

Correct answer: a