A 52-year-old female presents to A&E with her partner as he has concerns regarding a recent change in behaviour. He reports she has been confused at home for the past 2 days. She is unable to give a history. Observations: HR 95bpm, RR 21, O2 saturation 93% on room air, BP 89/65mmHg, temperature 38.1. On examination, she has coarse inspiratory crackles at the right base. Her blood test results show the following:

||||
|-------|:-------:|-------|
|Sodium|145 mmol/L|135 - 145|
|Potassium|3.6 mmol/L|3.5 - 5.3|
|Urea|6.5mmol/L|2.5 - 7.8|
|Creatinine|21 µmol/L|60 - 120|


A chest radiograph demonstrates right lower zone airspace opacification with air bronchograms.


Which of the following is the next best step in management?

Options:
explanation: This is incorrect because she has a CURB-65 score of 2. Patients with a score of 0 or 1 can be discharged for management within the community with oral antibiotics, such as amoxicillin (or doxycycline/clarithromycin if there is a penicillin allergy.) This patient also requires intravenous fluids due to the hypotension.
name: Discharge with a 5 day course of oral antibiotics
label: b
answer: no
explanation: This is incorrect because ITU admission is considered for patients with a CURB-65 score of 3 and above. This is because they are likely to require close monitoring, inotropic, or vasopressor support. The outreach team in the hospital are useful points of contact for patients who are critically unwell. This patient doesn't currently display any need for ITU support; she is slightly hypotensive but a trial of intravenous fluids will be needed in the first instance, and her hypoxia is likely correctible with a small amount of oxygen therapy.
name: Contact the outreach team and consider ITU admission
label: c
answer: no
explanation: This is incorrect because this patient should not be discharged home unless they are clinically well and have a CURB-65 score of 0 or 1. It is important to give all patients correct safety netting if they go home, however this patient needs IV antibiotics and fluids and has a confirmed source of infection, which needs treatment.
name: Discharge patient with safety netting advice
label: d
answer: no
explanation: This is the correct answer because this patient has community-acquired pneumonia and a CURB-65 score of 2 for confusion and systolic blood pressure <90mmHg. The CURB-65 score is used to guide management and prognosticate in community acquired pneumonia. Pneumonia typically presents as shortness of breath, productive cough, pleuritic chest pain, and fever. On examination, you can hear focal coarse inspiratory crepitations. This patient should be admitted as she will need IV antibiotics and fluids, which she cannot have within the community.
name: Admit patient to the medical ward and start intravenous antibiotics
label: a
answer: yes
explanation: This is incorrect because DOACs are not the correct treatment for community-acquired pneumonia. DOACs are the correct treatment for a pulmonary embolism, which could present in a similar manner. However, given the chest X-ray findings, the clinical presentation is better explained by a pneumonia at this moment.
name: Admit patient to the medical ward and start a direct oral anti-coagulant (DOAC)
label: e
answer: no

Correct answer: a


Learning point: A CURB-65 score of 2 or higher indicates a moderate risk of mortality in pneumonia patients, suggesting that management should include hospital admission, and treatment with intravenous antibiotics and supportive care