Cardio: Regular rate and rhythm without murmur, rub or gallop
Abdomen: Soft and nontender without rigidity, rebound or guarding. No bruising or distention
The general appearance of the patient will also help with assessing for pneumonia—eg, respiratory distress may be manifested by nasal flaring, use of accessory muscles, diaphoresis, or position.
The state of hydration may help with assessment of a longer-term illness; be vigilant for poor skin turgor, dry mucous membranes, and lack of urine output.
Lung exam may be normal or reveal rales (crackles), rhonchi, wheezing, bronchial breath sounds, whispered pectoriloquy (ie, examiner can hear a patient whispering when auscultating over an area of lung consolidation), or egophony (when auscultating over an area of lung consolidation the sound of a spoken vowel—eg, a long “eee” sound will be changed to a short “e”).
Diagnosis
X-ray shows faint, fluffy appearing small nodular opacities in the lower left lung, with associated thickening of interstitial and bronchial markings. Mild central peribronchial thickening is present bilaterally. There is no consolidation or effusion. Heart and mediastinum are normal. This, combined with physical exam findings, leads to a diagnosis of mycoplasma pneumonia.
The antibiotic of choice would be a macrolide antibiotic, though a second-generation tetracycline (eg, doxycycline) may be used. Follow-up should be with primary care or by a return to the urgent care if symptoms persist, or with a more severe illness. Note that symptoms may persist for weeks.
Learnings
Mycoplasma pneumonia is one of the most commonly identified pneumonias in young adults, particularly in the summer months. It is caused by a bacterium, mycoplasma pneumoniae, that lacks a cell wall.
Symptoms of pneumonia may include fever, chills, cough, shortness of breath, myalgias, chest pain and fatigue. Risk factors include being elderly, a smoker, immunocompromised status. It is important to inquire about recent hospitalizations, as a facility-acquired pneumonia will require a different approach to management than a community- acquired pneumonia.
Ask specifically about comorbidities such as alcoholism, IV drug use, cystic fibrosis, history of bronchiectasis, and exposures to ill persons.
Testing initially involves a plain x-ray series. Mycoplasma will often appear as a patchy infiltrate, either unilateral or bilateral. Lobar consolidation is rare. Assess for other serious causes, including pneumothorax, mass, mediastinal air, rib fractures, or parapneumonic effusion. Laboratory testing is rarely indicated in the young, healthy patient. Other testing not generally helpful in an outpatient setting include blood cultures, sputum culture, urinary antigens, arterial blood gas, or viral antigens.
Differential Diagnosis
- Lobar pneumonia from pneumococcus
- Pneumocystis pneumonia
- Lung cancer with metastatic disease
- Mycoplasma infection
- Cardiomegaly secondary to heart failure
Physical Examination
Examination reveals the following:
Vitals: Afebrile, pulse 102, respirations 20, BP 122/78
General: Alert and oriented, no acute distress
Lungs: Clear to auscultation on the right but a slight wheeze is heard on the left with expiration
Cardio: Regular rate and rhythm without murmur, rub or gallop
Abdomen: Soft and nontender without rigidity, rebound or guarding. No bruising or distention
The general appearance of the patient will also help with assessing for pneumonia—eg, respiratory distress may be manifested by nasal flaring, use of accessory muscles, diaphoresis, or position.
The state of hydration may help with assessment of a longer-term illness; be vigilant for poor skin turgor, dry mucous membranes, and lack of urine output.
Lung exam may be normal or reveal rales (crackles), rhonchi, wheezing, bronchial breath sounds, whispered pectoriloquy (ie, examiner can hear a patient whispering when auscultating over an area of lung consolidation), or egophony (when auscultating over an area of lung consolidation the sound of a spoken vowel—eg, a long “eee” sound will be changed to a short “e”).
Diagnosis
X-ray shows faint, fluffy appearing small nodular opacities in the lower left lung, with associated thickening of interstitial and bronchial markings. Mild central peribronchial thickening is present bilaterally. There is no consolidation or effusion. Heart and mediastinum are normal. This, combined with physical exam findings, leads to a diagnosis of mycoplasma pneumonia.
The antibiotic of choice would be a macrolide antibiotic, though a second-generation tetracycline (eg, doxycycline) may be used. Follow-up should be with primary care or by a return to the urgent care if symptoms persist, or with a more severe illness. Note that symptoms may persist for weeks.
Learnings
Mycoplasma pneumonia is one of the most commonly identified pneumonias in young adults, particularly in the summer months. It is caused by a bacterium, mycoplasma pneumoniae, that lacks a cell wall.
Symptoms of pneumonia may include fever, chills, cough, shortness of breath, myalgias, chest pain and fatigue. Risk factors include being elderly, a smoker, immunocompromised status. It is important to inquire about recent hospitalizations, as a facility-acquired pneumonia will require a different approach to management than a community- acquired pneumonia.
Ask specifically about comorbidities such as alcoholism, IV drug use, cystic fibrosis, history of bronchiectasis, and exposures to ill persons.
Testing initially involves a plain x-ray series. Mycoplasma will often appear as a patchy infiltrate, either unilateral or bilateral. Lobar consolidation is rare. Assess for other serious causes, including pneumothorax, mass, mediastinal air, rib fractures, or parapneumonic effusion. Laboratory testing is rarely indicated in the young, healthy patient. Other testing not generally helpful in an outpatient setting include blood cultures, sputum culture, urinary antigens, arterial blood gas, or viral antigens.
What to Look For
Differential diagnostic considerations for cough and shortness of breath are broad, including etiologies as diverse as acute coronary syndrome, pulmonary embolism, malignancy, cardiac tamponade, and pneumothorax; however, the most common causes are infectious, ranging from acute viral bronchitis to bacterial pneumonia.
Indications for transfer include the following:
- Respiratory distress
- Tachypnea
- Retractions
- Associated diaphoresis
- Drooling or stridor
- Altered level of consciousness
- Oxygen saturation less than 90%
- Concern for a pathogen with increased virulence such as methicillin-resistant staph aureus (MRSA) or an atypical pneumonia, such as pneumocystis pneumonia
- Concern about compliance or inability to ensure good care at home
- Toxic appearing or with underlying medical conditions that predispose to complications
- Respiratory distress
- Tachypnea
- Retractions
- Associated diaphoresis
- Drooling or stridor
- Altered level of consciousness
- Oxygen saturation <90%
- Concern for a pathogen with increased virulence such as methicillin-resistant staph aureus (MRSA) or an atypical pneumonia, such as pneumocystis pneumonia
- Concern about compliance or inability to ensure good care at home
- Toxic appearing or with underlying medical conditions that predispose to complications