What is the most likely diagnosis for a patient with pleuritic chest pain, hoarseness, and auscultatory crackles?

Pneumonia (Community-Acquired Pneumonia)

This patient most likely has pneumonia—the combination of pleuritic chest pain ("pain in lungs"), hoarseness (likely from cough or upper airway inflammation), and crackles on auscultation represents the classic triad of lower respiratory tract infection with parenchymal involvement. 1, 2

Key Diagnostic Features Present

Crackles (Rales)

• Focal crackles are present in approximately 81% of pneumonia patients and represent the sudden opening of collapsed alveoli and airways filled with inflammatory exudate 2, 3
• Focal auscultatory abnormalities increase pneumonia probability from 5-10% baseline to 39% 2
• Crackles combined with breathlessness and absence of rhinorrhea significantly increases pneumonia likelihood 1, 3

Pleuritic Chest Pain

• Sharp chest pain that worsens with breathing is a characteristic symptom supporting pneumonia diagnosis 1
• Pleuritic pain indicates pleural irritation from underlying parenchymal inflammation 4, 1

Hoarseness (Voice Loss)

• While hoarseness itself is not specific for pneumonia, it commonly accompanies the persistent cough and upper airway inflammation seen in respiratory infections 1
• New cough with or without sputum production is a cardinal symptom of pneumonia 1

Immediate Diagnostic Algorithm

Step 1: Assess Vital Signs 1, 2

• Check temperature (fever ≥38°C strongly suggests pneumonia)
• Measure respiratory rate (tachypnea >24 breaths/min increases probability)
• Obtain oxygen saturation (SpO₂ <92% on room air supports pneumonia diagnosis)

Step 2: Complete Physical Examination 1, 2

• Listen for diminished breath sounds in affected areas (indicates consolidation)
• Percuss for dullness (highly specific when present)
• Assess for pleural rub (highly specific but uncommon)
• Check for increased tactile fremitus (indicates consolidation)

Step 3: Order Chest Radiography 4, 1, 2

• Chest X-ray (PA and lateral) is the gold standard and should be obtained immediately when pneumonia is suspected based on crackles plus respiratory symptoms 4, 2
• The American College of Chest Physicians recommends chest radiography when patients have acute cough with abnormal vital signs or focal chest findings 1

Step 4: Consider Adjunctive Laboratory Testing 1, 3

• If vital signs are normal but crackles persist, measure C-reactive protein (CRP)
• CRP >30 mg/L significantly increases pneumonia likelihood and warrants chest X-ray 1, 3
• CRP <10 mg/L makes pneumonia less likely 3

Critical Clinical Decision Points

When Pneumonia is Highly Likely (Proceed to Imaging + Empiric Antibiotics)

• Fever ≥38°C + tachypnea + focal crackles 1, 2
• Dyspnea + focal crackles + absence of rhinorrhea 1, 3
• Pleuritic chest pain + crackles + productive cough 1

When Pneumonia is Unlikely (Consider Alternative Diagnosis)

• Normal vital signs AND normal lung examination has 97% negative predictive value for pneumonia 2
• Absence of tachypnea combined with normal breath sounds effectively rules out pneumonia 2, 5

Important Caveats and Pitfalls

Do Not Rely on Auscultation Alone 2

• Lung ultrasound has superior sensitivity (93-96%) compared to chest X-ray (64-87%) and can detect pneumonia missed by auscultation 2
• Normal auscultation does not exclude pneumonia, particularly in early disease 4

Wheezing Does Not Exclude Pneumonia 2, 3

• Wheezing alone does not significantly increase or decrease pneumonia likelihood 3
• Do not assume asthma or bronchitis based solely on wheezes 2

Elderly Patients Require Higher Suspicion 3

• Elderly patients (≥65 years) may present without classic findings including crackles or fremitus 3
• Altered mental status may be the primary presenting symptom in older adults 1

Crackles Can Be Transient 6

• Placement in lateral decubitus positions may elicit crackles not heard in upright position 6
• Persistent crackles that do not clear with coughing are more specific for pneumonia 6

Immediate Management

Obtain Chest X-Ray Promptly 4, 1

• PA and lateral views are preferred over portable AP when feasible 4
• Imaging confirms diagnosis and identifies complications (effusion, abscess) 4

Initiate Empiric Antibiotics 3

• Start antibiotics according to local guidelines if imaging cannot be obtained immediately and clinical suspicion is high 3
• Modify therapy based on chest X-ray findings, severity, and risk factors 1

Reassess in 48-72 Hours 1

• Ensure clinical improvement on therapy 1
• Consider alternative diagnoses or complications if no improvement 1