![]() ![]() In one study, 27.3% of the patients admitted from the emergency department (ED) with a diagnosis of pneumonia ultimately had another diagnosis on discharge.( 3) Rates of overdiagnosis may have increased over time, a trend that may be driven, at least in part, by the Centers for Medicare & Medicaid Services (CMS) core performance measures focusing on timely antibiotic administration for CAP.( 4) Although equally important, underdiagnosis of pneumonia, such as this case, is not as well-described.ĭiagnosing pneumonia requires integration of a number of symptoms and physical exam findings, as no one symptom or sign is sufficient to make the diagnosis. Most literature regarding misdiagnosis of pneumonia describes overdiagnosis: attributing a constellation of clinical signs as symptoms to pneumonia ultimately found to be caused by another condition. The CommentaryĮvery year, more than 4 million Americans are diagnosed with community-acquired pneumonia (CAP), resulting in significant morbidity, mortality, and a total cost of more than $10 billion.( 1) Guidelines dictate that the diagnosis of CAP requires the presence of clinical features suggestive of acute respiratory infection coupled with an acute infiltrate demonstrable by chest radiograph or other imaging modality.( 2) As this case demonstrates, however, the clinical signs and symptoms associated with CAP are nonspecific, and radiographic imaging is not always diagnostic, resulting in potential for misdiagnosis. The patient quickly improved on antibiotics and was discharged 2 days later. The patient was started on antibiotics and admitted for pneumonia with effusion. However, a chest radiograph now showed a right-sided effusion with consolidative changes, and a thoracentesis was consistent with parapneumonic effusion. Laboratory test results, including CBC and BMP, were unremarkable. Examination was significant for tachycardia at 105 beats per minute, mild tachypnea at 20 breaths per minute, and diminished right-sided lung sounds. The patient returned to the ED 3 days later reporting worsening pain and continued fever with new cough and dyspnea. Discharge diagnoses were "fever, pleural effusion, and chest wall pain." The patient was discharged home with prescriptions for oxycodone/acetaminophen and ibuprofen. Although the clinicians had a high suspicion for pulmonary embolism (PE), a computed tomography angiogram (CTA) chest demonstrated moderate right pleural effusion without evidence of PE or infiltrate. Initial workup included a normal complete blood count (CBC) and basic metabolic panel (BMP), an elevated D-dimer (666 μg/mL), and a moderate right pleural effusion on chest radiograph. No heart or lung abnormalities were noted on exam. On arrival to the ED, the patient was tachycardic at 106 beats per minute, tachypneic at 24 breaths per minute, and febrile to 38.8° C orally. The patient had taken a 2-hour plane ride the day before onset of symptoms. Review of systems was negative for cough or dyspnea, and medical, surgical, and social history were unremarkable. A 32-year-old man presented to the emergency department (ED) with 3 days of fever and right pleuritic chest pain. ![]()
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