What is the appropriate workup and initial management for a 72‑year‑old woman presenting with cough, tachypnea, and fever?

Workup for 72-Year-Old Female with Cough, Fast Breathing, and Fever

This patient requires immediate assessment for community-acquired pneumonia with chest radiography, vital signs monitoring including oxygen saturation, and risk stratification for complications given her age >65 years.

Immediate Clinical Assessment

Suspect pneumonia when any of the following are present: new focal chest signs, dyspnea, tachypnea, pulse rate >100, or fever >4 days 1. In this 72-year-old with cough, tachypnea, and fever, pneumonia is highly likely and must be confirmed or excluded immediately.

Physical Examination Priorities

• Auscultate for focal abnormalities (crackles, diminished breath sounds, dull percussion, bronchial breathing)—the presence of focal findings raises pneumonia probability from 5-10% to approximately 39% 1.
• Check vital signs systematically: pulse >100, temperature >38°C, respiratory rate >30, and blood pressure <90/60 mmHg are all markers of complicated course in patients >65 years 1.
• Measure oxygen saturation—SpO₂ of 94% or lower on room air is borderline and warrants serial monitoring 2.
• Assess mental status—confusion or diminished consciousness indicates high complication risk 1.

Diagnostic Testing Algorithm

First-Line Imaging

Obtain a chest X-ray immediately to confirm or reject the diagnosis of pneumonia 1. In elderly patients presenting with fever, tachypnea, and cough, radiographic confirmation is required because clinical features alone cannot reliably differentiate pneumonia from acute bronchitis 2.

Laboratory Workup

• C-reactive protein (CRP): A level <20 mg/L with symptoms >24 hours makes pneumonia highly unlikely; a level >100 mg/L makes pneumonia likely 1.
• Complete blood count with differential to evaluate for leukocytosis patterns supporting infectious etiology 2.
• BNP or NT pro-BNP if left ventricular failure is suspected (BNP <40 pg/mL or NT pro-BNP <150 pg/mL makes heart failure unlikely) 1.

Microbiological Testing

Microbiological tests such as cultures and gram stains are not recommended in primary care 1. However, if the patient requires hospitalization, blood cultures and sputum cultures should be obtained before initiating antibiotics 3.

Critical Differential Diagnoses to Exclude

Left Ventricular Failure

Consider in patients >65 years with orthopnea, displaced apex beat, and/or history of myocardial infarction, hypertension, or atrial fibrillation 1. This is particularly important as cardiac failure can mimic pneumonia in the elderly.

Pulmonary Embolism

Consider if the patient has history of DVT or pulmonary embolism, immobilization in the past 4 weeks, or malignant disease 1.

Aspiration Pneumonia

Consider in patients with difficulties swallowing who show signs of acute LRTI; perform chest X-ray in these patients 1.

Chronic Airway Disease

In elderly patients who smoke and present with cough, COPD should be considered 1. Look for wheezing, previous consultations for wheezing or cough, dyspnea, prolonged expiration, and smoking history 1.

Risk Stratification for Complications

This patient is at elevated risk for complications based on age >65 years alone 1. Additional high-risk features to assess include:

• Presence of COPD, diabetes, or heart failure 1
• Previous hospitalization in the past year 1
• Taking oral glucocorticoids 1
• Antibiotic use in the previous month 1
• General malaise 1
• Absence of upper respiratory symptoms 1
• Active malignant disease, liver disease, renal disease, or other immunocompromising conditions 1

Patients with elevated risk should be monitored carefully and referral to hospital should be considered 1.

Initial Management Considerations

If Pneumonia is Confirmed

Empiric antimicrobial regimens should consist of either a beta-lactam plus a macrolide or a respiratory fluoroquinolone alone 3. First-line agents include tetracycline or amoxicillin, with newer macrolides (azithromycin, roxithromycin, or clarithromycin) as alternatives in patients with β-lactam hypersensitivity 2.

Adherence to IDSA/ATS guidelines improves in-hospital mortality (8% vs 17%), length of hospital stay (8 vs 10 days), and time to clinical stability in elderly patients with CAP 3.

If Pneumonia is Excluded

If chest X-ray is normal and pneumonia is ruled out, consider post-infectious cough or acute bronchitis. Antibiotics are contraindicated for post-infectious cough or acute bronchitis unless there is confirmed bacterial sinusitis or early pertussis 2, 4.

Common Pitfalls to Avoid

• Do not rely solely on classic symptoms—pneumonia in the elderly (≥65 years) may present subtly, lacking typical acute symptoms (fever, cough, dyspnea, purulent sputum) observed in younger adults 3, 5.
• Do not miss atypical presentations—pneumonia should be suspected in all elderly patients with fever, altered mental status, or sudden decline in functional status, with or without lower respiratory tract symptoms 3, 5.
• Do not delay chest radiography when clinical suspicion is high based on vital signs and examination findings 1, 2.
• Do not prescribe antibiotics empirically without confirming pneumonia—if the diagnosis is uncertain after CRP testing, obtain chest X-ray before initiating antibiotics 1.