Symptoms of Pneumonia
Pneumonia should be suspected when a patient presents with acute cough plus at least one of the following: new focal chest signs, dyspnea, tachypnea, or fever lasting more than 4 days. 1
Core Clinical Symptoms
The typical symptom constellation includes:
- Cough (most common and persistent symptom, often lasting 14 days or longer) 1, 2
- Fever or hypothermia (temperature >38°C or ≤36°C), though fever typically resolves within 3 days of treatment 1, 3
- Dyspnea (shortness of breath) 1, 4
- Pleuritic chest pain (sharp, stabbing pain worsened by breathing or coughing) 1, 4
- Purulent sputum production 4
- Rigors and sweats 1
- Fatigue and myalgias (muscle aches), with fatigue often persisting for 14 days 1, 2
Atypical Presentations
Elderly patients frequently present without classic symptoms and may instead show:
- Confusion or altered mental status 5, 1
- Failure to thrive or worsening of underlying chronic illness 1
- Falls 1
- Absence of fever 1
Physical Examination Findings
Key signs on examination include:
- Abnormal breath sounds and crackles (brief, discontinuous sounds indicating fluid in airways) 1
- Tachycardia (pulse >100 beats/minute) 5, 1
- Tachypnea (respiratory rate >30 breaths/minute) 5
- Hypotension (blood pressure <90/60 mmHg) 5, 1
- Pleural friction rub (coarse, grating sound heard during both inspiration and expiration, indicating pleural inflammation) 1
Time Course of Symptom Resolution
Understanding expected recovery helps guide follow-up:
- Fever: Resolves within 3 days in most cases 2
- Dyspnea and pleuritic pain: Improve within 3-7 days 2
- Cough and fatigue: Persist longest, typically 14 days or more 2
- Complete symptom resolution: Takes more than 28 days in 35% of patients 2
Red Flags Requiring Urgent Evaluation
Patients should be referred to hospital if they have:
- Severe illness markers: Tachypnea, tachycardia, hypotension, and confusion 5
- High-risk comorbidities: Diabetes, heart failure, moderate-to-severe COPD, liver disease, renal disease, or malignancy 5
- Failure to respond to antibiotics within 72 hours 5
- Clinical deterioration within 24-48 hours of starting treatment 5
Diagnostic Confirmation
- Chest radiograph is mandatory to confirm pneumonia diagnosis and differentiate from other conditions 1
- Pulse oximetry should be performed to assess oxygen saturation 1
- Testing for COVID-19 and influenza is essential when these viruses are circulating in the community 3
Common Pitfalls
Patients should be advised to return if:
- Symptoms persist beyond 3 weeks 5
- No clinical improvement occurs within 3 days of antibiotic therapy 5
- Fever exceeds 4 days 5
- Dyspnea worsens 5
- Consciousness decreases 5
Radiographic progression may occur initially after treatment starts and does not necessarily indicate treatment failure in mild-to-moderate cases, though it is a poor prognostic sign in severe pneumonia. 5