Treatment for Outpatient Uncomplicated Pleuritic Pain, Cough, and Shortness of Breath
For an outpatient presenting with pleuritic pain, cough, and dyspnea, first rule out pulmonary embolism and pneumonia through clinical assessment and appropriate testing, then initiate empiric antibiotics according to local guidelines if pneumonia is confirmed, while withholding antibiotics if clinical and radiographic evidence excludes pneumonia. 1
Initial Risk Stratification and Diagnostic Approach
Assess for Life-Threatening Causes First
- Pulmonary embolism must be excluded as it accounts for 5-21% of patients presenting with pleuritic chest pain and represents the most common life-threatening etiology 2, 3
- Consider PE particularly in patients with smoking history, as this increases thromboembolic risk 1
- Use validated clinical decision rules (Wells score, PERC rule) to guide PE workup 1
- If PE risk is intermediate or high, administer LMWH pending imaging 1
Evaluate for Pneumonia
Clinical features suggestive of pneumonia include: 1, 4
- Cough with dyspnea or pleuritic pain
- Fever ≥38°C, chills, sweats
- Tachypnea (respiratory rate >24/min)
- New focal chest examination findings (crackles, diminished breath sounds)
- Absence of runny nose significantly increases pneumonia likelihood 1, 5
Diagnostic Testing Algorithm
When to Order Chest Radiography
- Order chest X-ray if abnormal vital signs are present (fever ≥38°C, tachypnea, tachycardia) 1
- Chest radiography improves diagnostic accuracy and is required to confirm pneumonia 4, 6
C-Reactive Protein Measurement
- Measure CRP to strengthen diagnosis when pneumonia is suspected 1
- CRP >30 mg/L with suggestive symptoms strongly increases pneumonia likelihood 4, 5
- CRP <10 mg/L or 10-50 mg/L without dyspnea and daily fever makes pneumonia unlikely 4, 5
Tests NOT Recommended
- Do not routinely measure procalcitonin - it adds no diagnostic value beyond symptoms, signs, and CRP 1, 5
- Do not perform routine microbiological testing unless results would change therapy 1
Treatment Decisions Based on Findings
If Pneumonia is Confirmed (Clinical + Radiographic Evidence)
Initiate empiric antibiotics according to local and national guidelines 1, 4
For outpatients with no comorbidities:
- Macrolide (azithromycin) or doxycycline 7
For outpatients with comorbidities or recent antibiotic use (within 3 months):
- Respiratory fluoroquinolone (levofloxacin, moxifloxacin) OR
- Beta-lactam plus macrolide 7
Common pitfall: Azithromycin carries risks of QT prolongation, hepatotoxicity, and serious allergic reactions; consider these risks in elderly patients and those with cardiac conditions 8
If Pneumonia Cannot Be Confirmed but Imaging Unavailable
- Use empiric antibiotics per local guidelines when pneumonia is suspected but imaging cannot be obtained 1
If No Clinical or Radiographic Evidence of Pneumonia
- Do NOT use routine antibiotics when vital signs and lung examination are normal 1
- Consider viral pleurisy as the diagnosis 2, 3
- Treat with NSAIDs for pain management 2, 3
If Influenza is Suspected
- Initiate antiviral treatment within 48 hours of symptom onset (per CDC guidance) 1, 4
- Early antiviral therapy may decrease antibiotic use and hospitalization 1, 4
Critical Caveat: Pneumonia Masking Pulmonary Embolism
Be vigilant for PE even in confirmed pneumonia cases, especially if: 9
- Initial improvement with antibiotics followed by clinical worsening
- Persistent pleuritic chest pain despite appropriate pneumonia treatment
- Persistent cough with hemoptysis and breathlessness on exertion
In such cases, obtain CT pulmonary angiography to exclude PE 9