The symptoms of pneumonia include fever or hypothermia, rigours, sweats, cough, sputum production, change in sputum colour, pleuritic chest pain, shortness of breath, and tachypnea. Nonspecific symptoms or complaints, such as nausea, vomiting, abdominal pain, loss of appetite, fatigue, myalgias, arthralgias, and headache, occur in approximately 10% to 30% of patients with CAP. Among elderly patients, however, fever, cough, and shortness of breath are less commonly reported. As a result, the recognition and treatment of pneumonia may be delayed in this age group. In the absence of other complaints, confusion or altered mental status may be more common among elderly patients. Unfortunately, this constellation of symptoms is not useful in determining the specific bacterial cause of pneumonia. In patients with HAP, similar symptoms may be present; in patients with VAP, the symptoms may be less obvious and pneumonia more difficult to diagnose.
In addition to the symptoms described above, several findings consistent with pneumonia can be detected through noninvasive and invasive tests. Auscultatory changes such as altered air exchange, breath sounds, or rales may be detected. Chest radiography may show pulmonary infiltrates consistent with acute pneumonia. Signs of consolidation and tachypnea may also be found. Resolution of such symptoms may be delayed even if the patient receives appropriate antibiotic therapy. In CAP, for example, a majority (64.3% to 86.5%) of patients who have undergone treatment may experience at least one symptom of CAP several weeks after their initial presentation.
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Along with history and physical examination, noninvasive tests may include Gram staining, blood culture, sputum culture, and chest radiography, depending on the site of care (outpatient or inpatient). For most ambulatory patients with CAP, microbiologic investigations and chest radiography are not required. In contrast, culture of the sputum, blood, and other body sites, as well as chest radiography, is often performed for hospital inpatients. In conjunction with signs and symptoms, a chest radiograph aids in the diagnosis of pneumonia by characterizing the extent and severity of disease. In the absence of a chest radiograph, the differential diagnosis based on symptoms may include noninfectious causes (e.g., reactive airway disease, congestive heart failure, pulmonary embolism), as well as upper and lower respiratory tract infections. Depending on the severity of illness, invasive tests such as transtracheal or transthoracic aspiration, thoracentesis, open lung biopsy, or bronchoscopy (with protected specimen brush or bronchoalveolar lavage) may also be considered to aid in identifying a causative pathogen.