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  1. Here in our group, we have a friendly philosophical debate going on about getting x-rays to work up possible pneumonia. The current drama arises from a recent situation, in which a PA saw a patient who had a fairly benign presentation, but then returned 3 days later much sicker, and was diagnosed. Full details will be posted below, but before we get into the clinical data, the two sides of our little Civil War break down something like this: On "Team Osler," we have the argument that community-acquired pneumonia is a clinical diagnosis, and while the positive and negative predictive values of various individual signs or symptoms may not be especially convincing, there will be a gestalt, and a reason to order a chest x-ray in the first place. Having had a cough for a certain period of time, or being a certain age, may or may not constitute a reason, and it's okay if it's considered to be one, but it's also okay if it's considered not to be. And "because it might be pneumonia sometimes" is also viewed as a fairly weak reason. On "Team Roentgen," we have the argument that as urgent care clinicians, we do not have the continuity of care that would allow us to tell patient to come back in 2 days for a quick recheck. This side also advances the argument that a chest x-ray is not all that expensive, or all that much radiation. Therefore, the threshold for imaging can be lower, and "it's weird this cough hasn't gone away yet" or "sure he's not 75, but he's older than 60" could be viewed as reasons to get the films. So far, we have decided that this comes down to "practice style," which seems to be a nice way of saying that everybody is right. The problem is, in this case the patient was definitely sick 3 days later, so there is a somewhat annoying subtext going on, in which we appear to be arguing about whether it would have been possible to know on Tuesday what would happen by Friday. Okay, then, the specifics: The patient is a mid-60s man, who comes in with his wife because both of them have been dealing with a cough, on and off, for something like 4-6 weeks. It's not clear if the cough has ever really resolved, but it has been better and worse at different times. His cough is intermittently productive, of sputum that ranges from clear to thick and yellow. There is been no hemoptysis. He also denies fevers and chills, body aches, fatigue, loss of appetite, shortness of breath, or wheezing. At the time of the first visit, he has a temp of 98.2, without any antipyretics on board. His respiratory rate is 16. His oxygen saturation on room air is 98 percent. His lungs sound clear to a good, thorough listen (because of the cough and its duration). He is told that several people this year have had an annoying, lingering cough, and that he seems not to be dealing with bronchitis or pneumonia on that particular day. He is encouraged to run a humidifier, drink plenty of water, and keep close watch on his symptoms. If things get worse, he should come back. 3 days later, he does exactly that. On that day, he has a temp of 102.8, he describes body aches all over, he has been listless and sleepy, and his oxygen saturation is 92 percent on room air. This time, his lungs sound junky, and the clinician gets a chest x-ray, which shows a right lower lobe infiltrate. Digging around in the references has been a little bit unsatisfying. Everyone seems to agree that community-acquired pneumonia is a clinical diagnosis, but at the same time there is no particular agreement about symptoms that have terribly powerful positive or negative predictive value. For instance, the presence of fevers, purulent sputum, malaise, etc. works way better to positively predict pneumonia then the absence of those symptoms does to rule it out. As far as x-rays go, they aren't the end-all either, and work way better to prove the presence of pneumonia than its absence. It can absolutely exist without visible infiltrates, for example. The AAFP has a policy statement about use of ionizing radiation for imaging, but it doesn't mention chest xrays or pneumonia. So that's fun. So I'm the lucky chump who "missed" the pneumonia, or at least "didn't get the x-ray." ...OR AM I? Maybe I'm the guy who utilized resources appropriately, and educated the patient on red flag symptoms, which prompted a quick re-evaluation and response as soon as the pneumonia developed. The world may never know... but in your practice, what's the philosophy on this guy?
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