Community-Acquired Pneumonia in Adults

[To box 9 Outpatient management (see next page)]

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Source: Institute for Clinical Systems Improvement (ICSI). Community-acquired pneumonia in adults. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 May. 35 p. Community-Acquired Pneumonia in Adults Patient presents with symptoms suggesting community-acquired pneumonia Schedule provider visit. A Obtain chest x-ray, especially if patient has two or more of these signs: *Temp greater than 100 degrees F (37.8 degrees C). *Pulse greater than 100. *Decreased breath sounds. *Rales. *Respiratory rate greater than 20. Pneumonia Severity Index (PSI). Demographic Factors. Age. Males age (yrs). Females age (yrs) minus 10. Nursing home resident plus 10. Chest x-ray shows infiltrate or strong clinical suspicion of pneumonia? A Out of guideline Comorbid illnesses. Neoplastic disease plus 30. Liver disease plus 20. Heart failure plus 10. Cerebrovascular disease plus 10. Renal disease plus 10. Pneumonia diagnosed, calculate PSI (see box 6a). A Physical Examination Findings. Altered mental status plus 20. Respiratory rate greater than or equal to 30 per minute plus 20. Systolic BP less than 90 mmHg plus 15. Temperature less than 95 degrees F (35 degrees C) or greater than or equal to 104 degrees F (40 degrees C) plus 15. Pulse greater than or equal to 125 per minute +10. Evaluation of inpatient vs. outpatient management. 1. Pre-existing conditions? OR 2. PSI score greater than 90? OR 3. Clinical judgment? A Inpatient management. Out of guideline. Laboratory Findings. pH less than 7.35 plus 30. BUN greater than or equal to 30 mg / dL (11 mmol / L) plus 20. Sodium less than 130 mEq / L plus 20. Glucose greater than 250 mg / dL (14 mmol / L) plus 10. Hgb less than 9 gm (Hematocrit less than 30%) plus 10. PO2 less than 60 mmHg (O2 sat less than 90%) (room air) plus 10. Pleural effusion plus 10. Neoplastic disease - any cancer, except basal or squamous cell carcinoma of the skin, active at the time of presentation or within one year of presentation. Liver disease - clinical or histologic cirrhosis or chronic active hepatitis. To box 9 Outpatient management (see next page) CHF - documented with history, physical exam and CXR findings; echo, MUGA; or left ventriculogram. CVD - clinical diagnosis of stroke or TIA; or documented stroke on CT or MRI. Renal disease - chronic renal disease; or abnormal BUN or creatinine. A = Annotation All copyrights are reserved by the Institute for Clinical Systems Improvement, Inc.