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Pneumonia: who gets x-rayed, and when?

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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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I don't know of any philosophy in my office (we're a family practice), but I would have ordered the CXR on the first visit due to the cough lasting for 3 months. In my mind, any cough lasting for a month gets a CXR and spirometry / peak flow (depending on the presentation) unless my gut tells me to give antibiotics in which case I'll do a peak flow to see if I should give them HHN or not and I'll withhold on the CXR since its not going to change my management of the patient being that I'm already giving them Abx. I'm a new grad PA so I tend to over order tests and be very aggressive in my diagnostic tests and a little more conservative in my treatment regimens unless its an OTC medication for simple complaints like Rhinitis. So far its served me well. Sorry this happened to you. Bad luck IMO.

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This all happened more than a month ago, so it wasn't 3 months of a cough. See above - it was an intermittent cough, over 4-6 weeks. Does that change your reasoning at all?

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What were the physical exam findings during the first visit? Any Hx of asthma or COPD, travel, etc? Was there a source for the coughing? I've always liked to use the term snapshot in time when it comes to patients, so if I saw there were swollen nares and cobblestoning and no sinus tenderness, TMs clear, tonsils clear and lungs clear w/o any LNA and the cough was non-productive and a mild - intermittent then I would have not gotten the x-Ray and had just given some nasal steroids with a PO H1 blocker and told them to come back if it gets worse. But if it was a productive cough, or a non-productive cough without a source, or anything greater than the scenario I painted and I was on the fence of giving abx, I would have done the CXR and a phone follow up at least.

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My $.02 worth.  Cough of >1 mo. duration w/o clinical improvement warrants a CXR.  Rationale, less common processes aside from pneumonia (mass, TB, etc.).  Had such a case a year and a half ago with a 60's male, head/chest cold sx., and former smoker.  Told him come back in a month if not improving.  He returned three months later and CXR showed a mass, though his head cold sx. resolved within the usual ten days (ENT guidelines for rhinosinusitis/sinusitis updated earlier this year).  BTW, they also state that bacterial RS makes up <7% of all "sinus infection" presentations and more likely <5%.

 

My current guidelines that I give pts. states benign cough of three weeks duration w/o improvement warrants trial of abx..  If not improved after completion of abx. (now 4 weeks/month out) then check the CXR.  Median duration of a bronchitis cough is 17 days.  Only sputum colors of clinical significance are those associated with pneumococcal pneumonia and klebsiella pneumonia (they give you your diagnosis w/o a CXR), or gross hemoptysis obviously for which they'd be in the ED and not my clinic.  No clinical significance with green, yellow, white, clear, plaid, striped or any other descriptor that one can imagine.  There is no clinical significance with progression of color either.  Body has ability to change sputum colors w/o any known clinical significance.  I wish I could remember the source for the timing and such for this statement but it's been ingrained in my head for several years now.  

 

With regard to suspicion for pneumonia and need for arbitrary CXR, if pt. isn't high-risk, in my mind it reverts back to the most basic of questions.  Is the study, test, etc. going to alter my treatment plan?  No, thus no immediate CXR.  I do still stick with the recommendation of a f/u study at 4 weeks to confirm resolution (pesky masses like to hide in pneumonias on occasion.

 

For grins and giggles, I'll ask our SPs during our monthly visit (they aren't onsite) next week and see what their medical conglomerate does, or see if they even have a general policy.

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Thanks, Mess. That's the kind of thing I was hoping to get perspective on. Part of the issue here is the question of improvement -- this was a guy whose cough got a little better, then a little worse, then better, but it never went away. I'm starting to think I should probably loosen up on getting X-rays in that scenario, but it's tougher when there are no physical findings and the history is free of red flags as well.

 

Timon, based on what you're saying it sound like you would have handled it the same way I did. My rationale matches what you've laid out in post #4 there.

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Any cough lasting more than 4 weeks gets a CXR from me. I caught a huge lung abscess recently on a fairly benign, afebrile cough presentation. 

 

Certainly cough with high fever or a clinical pneumonia picture gets a CXR. It's such a low-risk screening test there is little reason not to do it if you suspect anything nefarious. 

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Any cough lasting more than 4 weeks gets a CXR from me. I caught a huge lung abscess recently on a fairly benign, afebrile cough presentation.

 

Certainly cough with high fever or a clinical pneumonia picture gets a CXR. It's such a low-risk screening test there is little reason not to do it if you suspect anything nefarious.

One additional thought to consider is your pt. population and their ability to pay for the study.
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Cough + fever gets either a positive flu test or a CXR.  (If flu pos and otherwise healthy, no CXR; if old and/or immunocompromised then CXR too). 

 

Cough for 4 wks probably ought to have a CXR.  I do not routinely do ABx or CXR for cough of 3 wks duration as cough from bronchitis can last for 21 days easily.  If I listen and there are bibasilar rales or focal rales, will consider CXR vs. empiric Tx.  If young and healthy, likely will do empiric ABx.  If older and questionable Hx, CXR. 

 

If cough is of short duration and neg exam without fever, no CXR or ABx.  If I find alternate source of cough I treat that and have the Pt f/u - things like postnasal drip, allergic rhinitis/rhinosinusitis, sometimes even Eustachian tube dysfunction.  In the situation you described I would have considered this to be possibly allergic rather than infectious given his lack of S/Sx of infection.  I would also have considered asthmatic syndromes, reactive airway, etc.  At any rate, don't kick yourself too bad.

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Never see it mentioned here but find it hard to believe that when you see the same type of pt. one right after the other that you don't notice the vertical posterior wall erythema with normal pharynx on either side ("center yellow line of a two lane road") which is due to nasal drip with secondary pharyngitis and cough. Fix the drip and fix the throat/cough, with the cough obviously being the last to go.

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Any mid 60 year old with a month long cough as chief complaint gets x rayed in my book. That could be many other things besides PNA as well.

 

Young and healthy with great vitals and exams or other clear cause of cough (post nasal drip for example) - ok to defer x Ray. Fairly healthy and giving empiric abx - sometimes ok to defer. Anyone older or sick with cough beyond a couple or few days deserves imaging.

 

Lung exam is not sensitive for PNA. When the pt is older I'd always opt for imaging.

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One additional thought to consider is your pt. population and their ability to pay for the study.

 

Yeah, see, that's something I'm thinking about. One of the physicians who sits near me pointed out that he had an xray done and got a bill for $150 a few weeks later. All this time I've been trying to emphasize being careful with resources, and I'm reminded that by doing so, we also look out for patients' resources.

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Any mid 60 year old with a month long cough as chief complaint gets x rayed in my book. That could be many other things besides PNA as well.

 

Young and healthy with great vitals and exams or other clear cause of cough (post nasal drip for example) - ok to defer x Ray. Fairly healthy and giving empiric abx - sometimes ok to defer. Anyone older or sick with cough beyond a couple or few days deserves imaging.

 

Lung exam is not sensitive for PNA. When the pt is older I'd always opt for imaging.

 

Yeah, this is where I think I'm landing. Sure, odds of pneumonia were really low, so my not predicting it would be PNA is not anything I should worry too much about... but at the same time, there are plenty of pretty good reasons to get a CXR, and weird persistent coughs are among them. Besides, if the patient is 65 it's not the same as if they were 5, or 15, even if the ionizing radiation exposure were more of a thing.

 

Good discussion, everybody. Thank you. Keep it going.

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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?

4 vs 6 weeks does makes a difference to me, but if productive and 4 weeks and over 60. Probably would have gotten a CXR. However I would not judge someone who didn't. I would not call this a miss. Certainly have seen this presentation, minus the production, and not done a CXR until 6 weeks. If did CXR on any intermittent cough under 6 weeks, I would be doing A LOT of CXR.

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I don't know of any philosophy in my office (we're a family practice), but I would have ordered the CXR on the first visit due to the cough lasting for 3 months. In my mind, any cough lasting for a month gets a CXR and spirometry / peak flow (depending on the presentation) unless my gut tells me to give antibiotics in which case I'll do a peak flow to see if I should give them HHN or not and I'll withhold on the CXR since its not going to change my management of the patient being that I'm already giving them Abx. I'm a new grad PA so I tend to over order tests and be very aggressive in my diagnostic tests and a little more conservative in my treatment regimens unless its an OTC medication for simple complaints like Rhinitis. So far its served me well. Sorry this happened to you. Bad luck IMO.

 

Original poster said cough was duration of 4-6 weeks, not 3 months.

 

PLUS 

 

Coughs from acute bronchitis can certainly last 4-6 weeks, sometimes 8

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Original poster said cough was duration of 4-6 weeks, not 3 months.

 

PLUS

 

Coughs from acute bronchitis can certainly last 4-6 weeks, sometimes 8

I meant to write 3 weeks not 3 months, but 4-6 weeks, or 3 months, I'd still x-Ray it.. But you're more than welcome to practice on your own license however you like. I don't have x-Ray vision and I'm personally not willing to risk my license over a $45 out of pocket test that my patient can defer.. But at least I did my own due diligence..

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From UpToDate article on acute bronchitis:

 

"Chest x-ray — The indications for a chest x-ray in patients with an acute cough syndrome, to exclude pneumonia, are abnormal vital signs (pulse >100/minute, respiratory rate >24 breaths/minute, or temperature >38ºC), or rales or signs of consolidation on chest examination [6,7]. Patients of advanced age (over 75 years of age), however, may have pneumonia without mounting a significant fever [28]. Signs and symptoms suggesting pneumonia in this older population include tachypnea, decreased oxygen saturation, and decreased mental status, often displayed as behavioral change; chest x-ray should be ordered for such older patients who have a cough."

 

also

 

"Cough in patients with acute bronchitis usually lasts from 10 to 20 days [24]. Cough disappeared by day 14 in three-quarters of patients with viral bronchitis in one study [25]. In another study, the median duration of cough from all causes of acute bronchitis was 18 days, with a mean of 24 days [21]."

 

I likely wouldn't order a CXR for an acute cough in an otherwise healthy patient less than 65 y/o with a cough of 3 weeks.  As one study above says, this was the mean duration of all causes of bronchitis.  Waste of resources, increase harm to patient via radiation, and likely high number needed to treat.

There can be an argument for either empiric ABX or CXR at 4 weeks, but I see so many of these too where neither does anything to change outcome.

 

One argument that could be had for these lingering coughs in acute bronchitis is CXR vs empiric ABX first.  I have tried both, not sure where I stand.  Of course it depends on other factors such as PMHx, age, smoking hx, etc.

 

I think I'd tend to try empiric ABX in patients with subacute cough in the younger crowd.

 

Patients above 60, would probably get CXR before empiric ABX

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I likely wouldn't order a CXR for an acute cough in an otherwise healthy patient less than 65 y/o with a cough of 3 weeks. As one study above says, this was the mean duration of all causes of bronchitis. Waste of resources, increase harm to patient via radiation, and likely high number needed to treat.

There can be an argument for either empiric ABX or CXR at 4 weeks, but I see so many of these too where neither does anything to change outcome.

 

One argument that could be had for these lingering coughs in acute bronchitis is CXR vs empiric ABX first. I have tried both, not sure where I stand. Of course it depends on other factors such as PMHx, age, smoking hx, etc.

 

I think I'd tend to try empiric ABX in patients with subacute cough in the younger crowd.

 

Patients above 60, would probably get CXR before empiric ABX

So since the OPs patient is mid 60s (65+/-), and cough > 3 weeks (4-6 per OP) you would do the chest x-Ray and give abx then?

 

I'm just trying to clarify our difference of opinion here...

 

Also, Per UpToDate algorithm on evaluating sub-acute / chronic cough lasting >3 weeks is to do a chest x-Ray if there is no evidence of asthma, post nasal drip or GERD... (See attached algorithm)

post-89332-0-96345800-1455289015_thumb.png

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My $.02 worth.  Cough of >1 mo. duration w/o clinical improvement warrants a CXR.  Rationale, less common processes aside from pneumonia (mass, TB, etc.).  Had such a case a year and a half ago with a 60's male, head/chest cold sx., and former smoker.  Told him come back in a month if not improving.  He returned three months later and CXR showed a mass, though his head cold sx. resolved within the usual ten days (ENT guidelines for rhinosinusitis/sinusitis updated earlier this year).  BTW, they also state that bacterial RS makes up <7% of all "sinus infection" presentations and more likely <5%.

 

My current guidelines that I give pts. states benign cough of three weeks duration w/o improvement warrants trial of abx..  If not improved after completion of abx. (now 4 weeks/month out) then check the CXR.  Median duration of a bronchitis cough is 17 days.  Only sputum colors of clinical significance are those associated with pneumococcal pneumonia and klebsiella pneumonia (they give you your diagnosis w/o a CXR), or gross hemoptysis obviously for which they'd be in the ED and not my clinic.  No clinical significance with green, yellow, white, clear, plaid, striped or any other descriptor that one can imagine.  There is no clinical significance with progression of color either.  Body has ability to change sputum colors w/o any known clinical significance.  I wish I could remember the source for the timing and such for this statement but it's been ingrained in my head for several years now.  

 

With regard to suspicion for pneumonia and need for arbitrary CXR, if pt. isn't high-risk, in my mind it reverts back to the most basic of questions.  Is the study, test, etc. going to alter my treatment plan?  No, thus no immediate CXR.  I do still stick with the recommendation of a f/u study at 4 weeks to confirm resolution (pesky masses like to hide in pneumonias on occasion.

 

For grins and giggles, I'll ask our SPs during our monthly visit (they aren't onsite) next week and see what their medical conglomerate does, or see if they even have a general policy.

 

 

Any cough lasting more than 4 weeks gets a CXR from me. I caught a huge lung abscess recently on a fairly benign, afebrile cough presentation. 

 

Certainly cough with high fever or a clinical pneumonia picture gets a CXR. It's such a low-risk screening test there is little reason not to do it if you suspect anything nefarious. 

 

 

Agree with the above and then some!

 

 

One additional thought to consider is your pt. population and their ability to pay for the study.

 

 

honestly this should never enter your train of thought beyond just the thought... I have been burned a number of times by trying to do the patient a favor or save money.  You need to do it the same way every time for every patient.  Trying to save the patient $100 when they have lung CA or an empyema or some other pathology is unwise....  If they choose to decline the film that is fine, but always do the same work up if you believe it is best.

 

 

Cough + fever gets either a positive flu test or a CXR.  (If flu pos and otherwise healthy, no CXR; if old and/or immunocompromised then CXR too). 

 

Cough for 4 wks probably ought to have a CXR.  I do not routinely do ABx or CXR for cough of 3 wks duration as cough from bronchitis can last for 21 days easily.  If I listen and there are bibasilar rales or focal rales, will consider CXR vs. empiric Tx.  If young and healthy, likely will do empiric ABx.  If older and questionable Hx, CXR. 

 

If cough is of short duration and neg exam without fever, no CXR or ABx.  If I find alternate source of cough I treat that and have the Pt f/u - things like postnasal drip, allergic rhinitis/rhinosinusitis, sometimes even Eustachian tube dysfunction.  In the situation you described I would have considered this to be possibly allergic rather than infectious given his lack of S/Sx of infection.  I would also have considered asthmatic syndromes, reactive airway, etc.  At any rate, don't kick yourself too bad.

Again agreed

 

 

 

Any mid 60 year old with a month long cough as chief complaint gets x rayed in my book. That could be many other things besides PNA as well.

 

Young and healthy with great vitals and exams or other clear cause of cough (post nasal drip for example) - ok to defer x Ray. Fairly healthy and giving empiric abx - sometimes ok to defer. Anyone older or sick with cough beyond a couple or few days deserves imaging.

 

Lung exam is not sensitive for PNA. When the pt is older I'd always opt for imaging.

 

 

Yeah, see, that's something I'm thinking about. One of the physicians who sits near me pointed out that he had an xray done and got a bill for $150 a few weeks later. All this time I've been trying to emphasize being careful with resources, and I'm reminded that by doing so, we also look out for patients' resources.

 

"I tried to save the patient $100 and delayed Dx lung Cancer by 3 months" is not anything I would ever want to say on the stand, or have as though in my own head.

 

 

 

 

 

 

 

 

 

 

Additionally, if your facility is using digital x-rays the exposure is negligible... so not a worry -CT is a different issue

 

Early in my career I was very concerned with trying to save $$ for the patient and the system, as I have been burned a few times (nothing major but enough to get my attention) I have realized that owe the patient the same work up every time irrespective of their ability to pay. We offer the work up and then they can refuse it, but we still offer.

 

the Rad exposure for film is tiny with digital Xrays (I know.... there is no safe level of exposure.... but really)  And what is the true risk to a 65+ year old person.... it is not like they are 2 years old......

 

The expense is not huge but the risk of a miss is.... 

 

If you do not have a PCP ongoing relationship, another reason to get the film......  if you do not have a nurse calling them daily to see how they are doing (outstanding service) then get the film....

 

Overall, if there is a doubt, order the film

 

 

 

 

Also, I was always trained that CAP is a radiographic Dx - NOT a clinical... amazing how many abx scripts this saves!!

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On radiation exposure -

 

I forget the source, but the amount of radiation of 1 CXR is equivalent to that of flying across the country or living in Denver for a month.  The higher in the atmosphere that you are, the less the atmosphere protects you from solar radiation.  I once had a businesswoman complaining about radiation exposure, "I have a business meeting in Georgia next week so I want to be better by then.  I just got back from Minnesota."  She wanted ABx so I told her we could to a CXR and see if there was anything to treat and if not, no ABx.  "I don't want the radiation exposure."  I told her she's already had much more than a single xray from me would give her.  She got the xray.  No PNA.  No ABx. She got better after a couple of weeks of coughing. 

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I just skimmed the bulk of the posts, but I don't see much mention of possible differentials- you have a 65 year old male with a 5 week history of cough.  The vitals at that time seemed normal; as did the lung exam.  This in itself is the problem you need to address- why aren't more things showing up with this cough? You don't mention his fluid status, any edema, JVD; any history of recent medication changes.  No abdominal exam, this may show something irritating his diaphragm. 

I guess the point I'm trying to make is what did you write down to explain the significant cough in the setting of a normal (although brief) exam?  Personally, (and I've learned this the hard way) always look for the twist.  In school, we were trained to look for horses when we hear hoofbeats; I agree during the winter season, and with a wife with similar symptoms, viral URI is a good horse.  But in the environment of males, 65, theres a few more horses that I would want to make sure aren't there- CHF, COPD exacerbation, mass, pulmonary edema, spontaneous pneumothorax, among others.  These aren't zebras.  A zebra in this setting is polio, silicosis, MAC.  Granted, most people coming to an urgent care (or mostly anyone) will likely have a viral URI.  But include in your thoughts, exam, and notes an assessment of their fluid status, smoking and occupational exposure history, trauma- these are very cheap initially and will save you time in the long run.

 

I would have gotten the xray.  I've found 2 people with CHF exacerbations and one with an anterior sternal mass. 

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The comment regarding cost was in reference to an otherwise healthy individual with "short duration" of sx w/o significant concurrent sx. (healthy sick) who may have CAP w/o decompensation. CXR wouldn't change initial tx. so cost could be considered in overall equation (my population for example).

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