Makindo Medical Notes

Candidate Instructions 📋

You are a final-year medical student in the Acute Medical Unit. A 56-year-old patient has presented with cough and fever. Take a focused history, perform a targeted examination of the chest, and explain your initial differentials and management plan to the examiner. You are not required to perform invasive procedures.

Key History Points 📝

• ⏱️ Onset & Duration: Sudden vs gradual; days of fever, cough.
• 🌬️ Symptoms: Cough (productive vs dry), sputum colour, haemoptysis, pleuritic chest pain, breathlessness.
• 🌡️ Systemic: Fever, rigors, malaise, anorexia, confusion in elderly.
• ⚠️ Risk Factors: COPD, asthma, diabetes, immunosuppression, smoking, recent viral illness, alcohol excess.
• 📜 PMHx & DHx: Prior pneumonia, antibiotics, drug allergies.
• 👪 Social: Smoking, alcohol, occupational exposures (farm, birds, air-con → atypicals).

Examination Focus 👀

• 🫁 Inspection: Tachypnoea, accessory muscle use, cyanosis.
• 🫀 Obs: Fever, tachycardia, low SpO₂, hypotension.
• 🩺 Chest Signs: Reduced expansion, dull percussion, bronchial breathing, coarse crepitations, increased vocal resonance.
• 🧠 Confusion: Check GCS (CURB-65 scoring).

Differentials ⚖️

• 🌬️ Viral bronchitis (often dry cough, systemic upset, diffuse wheeze).
• 🫀 Heart failure (bilateral crepitations, orthopnoea, raised JVP).
• 🫁 Pulmonary embolism (pleuritic pain, haemoptysis, sudden dyspnoea).
• 🧫 TB (chronic cough, weight loss, night sweats, haemoptysis).
• 🦠 COVID-19 (depending on context, diffuse crackles, systemic features).

Investigations 🔬

• 🧪 FBC (↑ WCC, neutrophilia), U&E (renal function for antibiotics).
• 🩸 CRP/ESR for inflammation.
• 🫁 CXR: lobar consolidation (classical), interstitial pattern (atypicals).
• 🧪 Blood cultures & sputum culture before antibiotics.
• 🧪 Urinary antigens (Legionella, pneumococcus) in severe cases.
• 🫀 ABG if hypoxic.

Severity Assessment – CURB-65 📊

• C = Confusion (AMT ≤ 8)
• U = Urea > 7 mmol/L
• R = RR ≥ 30
• B = SBP < 90 or DBP ≤ 60
• 65 = Age ≥ 65 years

Score 0–1 = low risk (outpatient possible), 2 = hospital admission, ≥3 = severe (consider HDU/ICU).

Management 💊

• 🚑 Admit if moderate/severe, hypoxia, or comorbidity.
• 💉 Oxygen to maintain SpO₂ > 94% (or 88–92% if CO₂ retainer).
• 💊 Empirical antibiotics (per local guidelines; e.g. amoxicillin, doxycycline, or macrolide for atypicals).
• 💧 IV fluids if hypotensive or septic.
• 💊 Analgesia & antipyretics.
• 🦠 Treat sepsis per “Sepsis Six” if features present.
• 📈 Monitor: obs, sats, fluid balance, repeat CXR at 6 weeks (esp. if smoker >50 → exclude underlying malignancy).

Examiner’s Marking Guide 📋

• Identifies key symptoms (cough, fever, sputum, chest pain, breathlessness).
• Performs structured chest exam (inspection → palpation → percussion → auscultation).
• Mentions differentials & red flags (sepsis, hypoxia, confusion).
• Knows CURB-65 severity scoring.
• Explains empirical antibiotic choice and supportive management.
• Safe plan: admit, oxygen, IV fluids, antibiotics, monitor.

🧑‍⚕️ Case Examples — Pneumonia

• Case 1 (Community-Acquired Pneumonia): 🏡 A 45-year-old man presents with fever, productive cough, and pleuritic chest pain. CXR shows right lower lobe consolidation. CURB-65 = 1. Diagnosis: Mild community-acquired pneumonia (likely Streptococcus pneumoniae). Teaching point: Manage with oral amoxicillin for 5 days; review response at 48 h.
• Case 2 (Atypical Pneumonia — Legionella): 💧 A 52-year-old man returns from a hotel stay with fever, dry cough, diarrhoea, and confusion. Hyponatraemia is noted. CXR shows bilateral patchy infiltrates. Diagnosis: Legionella pneumonia. Teaching point: Consider atypical pathogens if extrapulmonary features are present; treat with macrolide or fluoroquinolone.
• Case 3 (Aspiration Pneumonia): 🤢 A 70-year-old woman with advanced dementia develops fever, cough, and foul-smelling sputum after choking on food. CXR shows right middle lobe consolidation. Diagnosis: Aspiration pneumonia. Teaching point: Cover anaerobes with co-amoxiclav or piperacillin-tazobactam; optimise swallowing assessment and feeding method.
• Case 4 (Complication — Empyema): 🧪 A 60-year-old man initially treated for pneumonia fails to improve, develops pleuritic chest pain and swinging fevers. CXR shows persistent effusion; pleural aspiration reveals frank pus. Diagnosis: Parapneumonic effusion with empyema. Teaching point: Requires chest drain + prolonged IV antibiotics; always investigate non-resolving pneumonia for complications.
• Case 5 (Complication — Lung Abscess): 🫁 A 50-year-old alcoholic man presents with 3-week history of fever, weight loss, and cough producing foul-smelling purulent sputum. CXR shows a cavitating lesion with air-fluid level. Diagnosis: Lung abscess (post-pneumonia complication). Teaching point: Prolonged antibiotics are needed; consider aspiration risk factors and exclude malignancy.