Respiratory · Full case

Chest Infections

NICE NG138 / CG191CRB-65 · antibiotic stewardshipPersistent → CXR (NG12)

Bronchitis vs pneumoniaAcute bronchitis (cough ± sputum, no focal chest signs, systemically well) is usually viral and self-limiting — antibiotics rarely help. Pneumonia (focal chest signs, fever, tachypnoea, hypoxia, systemic upset) is a different, potentially serious diagnosis. Examination separates them

CRB-65 stratifies CAPIn community-acquired pneumonia, CRB-65 (Confusion, Respiratory rate ≥30, BP <90/≤60, age ≥65) guides setting: 0 usually home, 1–2 consider hospital, 3–4 urgent admission. Use clinical judgement and consider oxygen saturations alongside

Stewardship: don't reflex-prescribeMost acute coughs/bronchitis are viral. NICE supports no antibiotic or a back-up (delayed) prescription for uncomplicated cases, with clear safety-netting — reducing resistance. Reserve immediate antibiotics for pneumonia, systemic illness or high-risk patients

Spot sepsis earlyA chest infection can be the source of sepsis: confusion, RR ≥22, hypotension, tachycardia, hypoxia, mottling, very high/low temperature, reduced urine output. Use a sepsis screen / NEWS2; sepsis is a time-critical emergency — admit and treat without delay

COPD exacerbations differIn COPD, an infective exacerbation (increased breathlessness, sputum volume/purulence) is managed with bronchodilators ± steroids ± antibiotics (per sputum purulence/criteria); have a lower threshold and a rescue-pack/self-management plan. Watch for type 2 respiratory failure

Persistent cough → think cancer/TBA cough/chest symptoms not resolving (e.g. >3 weeks, or pneumonia not clearing), especially in a smoker 40+, with haemoptysis, weight loss or persistent signs, needs a chest X-ray and the NICE NG12 lung-cancer pathway — and consider TB (cough >3 weeks, weight loss, night sweats, risk factors)

Follow up pneumoniaArrange a follow-up chest X-ray (~6 weeks) after pneumonia in smokers and those over 50 to ensure resolution and exclude an underlying lung cancer obstructing the airway. Safety-net for non-resolving or recurrent same-site infection

Protect the vulnerableThe elderly, frail, immunosuppressed, those with comorbidity/lung disease and the very young decompensate fastest and present atypically (confusion, falls, no fever). Lower the threshold to examine, investigate and admit; offer vaccination (flu, pneumococcal, COVID)

📋 Clinical Stem — Chest Infections

A 72-year-old man with 5 days of cough, fever and breathlessness, now confused and unsteady, whose daughter is worried he's "gone downhill fast"

Brian Côté, 72, is brought in by his daughter with 5 days of productive cough, fever and increasing breathlessness, and since yesterday he has become confused and unsteady on his feet — "not himself at all". He has COPD (ex-smoker, 40 pack-years) and type 2 diabetes. On arrival he looks unwell: respiratory rate 28, oxygen saturation 90% on air, heart rate 112, blood pressure 104/62, temperature 38.6°C, and he is disorientated to time and place with focal crackles at the right base. His daughter expected "just some antibiotics". He has not been eating or drinking much and his urine output is reduced.

This stem tests the ability to: distinguish a serious lower respiratory tract infection / community-acquired pneumonia from simple bronchitis; recognise that this patient is not a "just antibiotics" case but has features of sepsis and significant CAP (confusion, RR ≥22/≥30, hypoxia, tachycardia, borderline BP, reduced urine output, comorbidity) — to calculate CRB-65 and use a sepsis/NEWS2 assessment and arrange urgent admission rather than an outpatient prescription; to recognise atypical presentation in the elderly (confusion/falls); to manage antibiotic stewardship appropriately in milder cases but treat seriously here; and to safety-net and follow up (resolution CXR, NG12 if non-resolving). The SCA challenge is conveying to a worried daughter (who expected a prescription) why admission is needed, calmly and clearly.

Scenario A — CAP with sepsis (this stem) Elderly, comorbid, confused, hypoxic, tachypnoeic, hypotensive. CRB-65 high; sepsis features → urgent admission, oxygen, IV antibiotics/fluids per local sepsis pathway. NOT outpatient antibiotics.

Scenario B — Acute bronchitis (well adult) Cough ± sputum, no focal signs, systemically well. Viral; no/delayed antibiotic; self-care; safety-net. Stewardship.

Scenario C — CAP, low severity (CRB-65 0) Focal signs, fever, but well and stable. Home with oral antibiotics (amoxicillin first-line per local), safety-net, review.

Scenario D — Infective COPD exacerbation Increased breathlessness/sputum volume & purulence. Bronchodilators ± oral steroids ± antibiotics (purulence/criteria); rescue pack; watch for CO2 retention/type 2 failure.

Scenario E — Persistent/atypical Cough >3 weeks, haemoptysis, weight loss, non-resolving pneumonia, smoker 40+ → CXR + NG12 lung-cancer pathway; consider TB (cough >3 weeks, night sweats, risk factors).

Key variables to adapt for Bronchitis vs pneumonia; severity (CRB-65/NEWS2/sepsis); age/frailty/comorbidity & atypical presentation; COPD exacerbation; stewardship (no/delayed/immediate antibiotic); persistent symptoms → CXR/NG12/TB; resolution CXR & vaccination; the "just antibiotics" expectation.

Steps:

Step 1

History — Severity & Sepsis · Bronchitis vs Pneumonia · Risk · Persistent Symptoms · ICE

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The history must do three things fast: gauge severity and screen for sepsis; distinguish a self-limiting viral cough/bronchitis from pneumonia or a COPD exacerbation; and identify the high-risk patient and the persistent-symptom red flags (cancer/TB). Brian's confusion, breathlessness and systemic upset on a background of COPD and diabetes immediately mark him out as a serious presentation, not a prescription request.

🎓 SCA framing — manage the "just antibiotics" expectation honestly

"I can see you were hoping for antibiotics, and I understand why. But your dad is more unwell than a chest infection we'd treat at home — he's confused, his breathing and oxygen are affected — and that needs hospital assessment today, not just tablets."

Whether the case is mild (stewardship: explain why antibiotics may not help) or severe (this one: explain why tablets aren't enough), the skill is to address the expectation with a clear, honest rationale.

1A — Severity, type and risk

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me what's been happening — and what's changed that worried you enough to come today."	Captures the trajectory and the alarm. The daughter's "gone downhill fast" and the new confusion are the key signals. New confusion, rapid deterioration and breathlessness elevate this above a simple cough and point to pneumonia/sepsis in a vulnerable patient.In SCA: hearing the deterioration and the confusion, and reacting to them, is the pivotal step.	Confusion + deterioration → sepsis/CAP
🚩 Sepsis / severity screen"Is he confused or drowsy? Breathing fast? Passing less urine? Any dizziness, cold/mottled skin, or very high or low temperature?"	The safety core. Confusion, RR ≥22, hypotension, tachycardia, hypoxia, reduced urine output and temperature extremes are sepsis features (NEWS2/sepsis screen). Brian has several — this is potential sepsis from a chest source, a time-critical emergency.	Sepsis features → emergency admission, oxygen, IV antibiotics/fluids; don't delay.	Sepsis → admit + sepsis pathway
Bronchitis vs pneumonia vs COPD"Cough, sputum — colour/amount? Breathless beyond his usual? Chest pain on breathing? Is this his COPD flaring?"	Focal/pleuritic features, purulent sputum, breathlessness and systemic upset suggest pneumonia; a change in sputum volume/purulence with increased breathlessness on his baseline suggests an infective COPD exacerbation; a dry cough in a well patient suggests viral bronchitis. The distinction drives treatment intensity.	Pneumonia/COPD exacerbation → active treatment; viral bronchitis → stewardship.	Type → treatment intensity
Risk factors / vulnerability"What's his usual health — COPD, diabetes, other conditions? How's he normally, and how much worse is he now? Vaccinations?"	COPD, diabetes, age, frailty and immunosuppression raise risk and cause atypical presentation (confusion, falls, no fever). Baseline function frames how far he's deteriorated. Vaccination status (flu/pneumococcal/COVID) is relevant to prevention.	High-risk/comorbid → lower threshold to admit; atypical presentation.	Comorbidity → lower admission threshold
🚩 Persistent-symptom / cancer-TB screen"How long has the cough been there overall? Any coughing up blood, weight loss, night sweats? Smoking history?"	A cough not resolving (e.g. >3 weeks), haemoptysis, weight loss or night sweats — especially in a smoker 40+ — needs a chest X-ray and the NG12 lung-cancer pathway, and consideration of TB. Brian (40 pack-years) warrants a resolution CXR and vigilance even after the acute episode.	Persistent cough/haemoptysis/weight loss → CXR + NG12; ?TB.	Persistent → CXR (NG12) / TB
Hydration / oral intake / social"Is he eating and drinking? Who's at home, and could he manage there?"	Poor intake (Brian) worsens AKI risk and decompensation; social circumstances affect whether home management is even safe. These inform admission and support.	Poor intake/unsafe at home → admission/support.	Intake/social → disposition

1B — Red flags

🚨

Red Flags — the chest infection that is an emergency

Red flag	Why dangerous	Action
Sepsis — confusion, RR ≥22, hypotension, tachycardia, hypoxia, mottling, temp extremes, low urine output	Time-critical; organ dysfunction and death without rapid treatment.	Emergency admission; oxygen; IV antibiotics + fluids per sepsis pathway; NEWS2
High CRB-65 / severe CAP	High mortality; needs hospital-level care.	Urgent admission
Respiratory failure / severe hypoxia / exhaustion	Especially type 2 failure in COPD — may need NIV/ventilation.	Oxygen (target sats; care in COPD); urgent admission
Significant haemoptysis / suspected PE / pneumothorax	Alternative serious diagnoses presenting as "chest infection".	Urgent assessment/admission as indicated
Persistent/non-resolving symptoms, haemoptysis, weight loss (smoker 40+)	Lung cancer / TB.	CXR + NICE NG12 pathway; consider TB
Vulnerable patient deteriorating atypically (confusion, falls, no fever)	Elderly/immunosuppressed decompensate fast and silently.	Low threshold to examine/investigate/admit

1C — ICE

💭 Ideas

"What were you hoping we'd do today — and what do you think is going on?"

The daughter expects antibiotics. Surfacing this lets you respect the worry behind it while explaining why this presentation needs more than tablets — turning a potential conflict into shared understanding.

😟 Concerns

"What's frightened you most about how he's been?"

Her concern is the rapid change and the confusion. Naming it validates her for bringing him and lets you align: that confusion is exactly why he needs urgent assessment.

🎯 Expectations

"Let me explain what I'm worried about and what needs to happen next."

Reframing from "antibiotics at home" to "urgent hospital assessment" must be done clearly and compassionately, so she understands and agrees rather than feeling dismissed.

1D — Psychosocial context

Chest infections sit at two poles of the same consultation skill. At one pole is the well adult who wants antibiotics for a viral cough — where the art is to explain stewardship and safety-net without leaving them feeling fobbed off. At the other is the frail, comorbid older patient whose "chest infection" is actually pneumonia and sepsis, presenting atypically with confusion — where the art is to recognise severity behind a family's modest expectation and act decisively. Both require reading severity accurately and communicating the plan with clarity and empathy.

🏥 Reframing to admission

Explain clearly why home antibiotics aren't safe here.

"I know hospital wasn't what you expected, but his confusion and low oxygen tell me his body's under real strain. Treating this properly — with oxygen, fluids and antibiotics into a vein — needs to happen in hospital, today."

💊 Stewardship (milder cases)

For the well patient, explain why antibiotics may not help.

"Most chest infections like this are viral, so antibiotics often don't help and can cause side effects. I'll give you a 'just-in-case' prescription to use only if you're not improving, and tell you exactly what to watch for."

👪 Supporting the family

Acknowledge their worry and role.

"You did exactly the right thing bringing him in — you know him best, and 'not himself' is an important sign. Let's get him the help he needs."

🛡️ Prevention

Vaccination and self-management for at-risk patients.

"Once he's through this, we'll make sure his flu, pneumonia and COVID jabs are up to date and his COPD plan is solid — that reduces the chance of this happening again."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Is he confused, breathing fast, passing less urine?" — screens for sepsis.

"This is more than a chest infection for tablets at home — he needs hospital today." — acts on severity.

(milder case) "Antibiotics often don't help a viral cough — here's a back-up prescription and what to watch for." — stewardship + safety-net.

Deductions

Prescribing oral antibiotics and sending a septic patient home
Not screening for sepsis / not calculating CRB-65
Missing atypical presentation in the elderly
(milder) reflex antibiotics with no stewardship/safety-net

🔴 Red

Septic patient given oral antibiotics + sent home; no sepsis screen/CRB-65; severity missed; no safety-net

🟠 Amber

Recognises serious infection; some severity assessment; admission considered but not decisive; ICE partial

🟢 Green

Screens sepsis + CRB-65/NEWS2; distinguishes pneumonia/COPD/bronchitis; recognises atypical severity in the elderly; decisive admission; stewardship in milder cases; ICE all three; safety-net

Step 2

Triage — Sepsis/Severe CAP · COPD/Moderate · Self-Limiting

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Triage in chest infection is severity-led: sepsis or severe CAP → emergency admission; moderate CAP/COPD exacerbation → treat actively ± admit by CRB-65/judgement; well patients with bronchitis → self-care + stewardship. Brian is firmly in the emergency lane.

🔴 Emergency

Same day / 999

Admit

Sepsis / severe CAP (high CRB-65/NEWS2)Oxygen, IV antibiotics + fluids, urgent admission (Brian)
Respiratory failure / severe hypoxiaOxygen (care in COPD); admit
Alternative emergency (PE/pneumothorax)Urgent assessment

🟠 Moderate

Treat ± admit

By severity

CAP CRB-65 1–2Consider hospital; oral/IV antibiotics; review
Infective COPD exacerbationBronchodilators ± steroids ± antibiotics; rescue pack
Vulnerable/comorbidLower admission threshold; close review

🟢 Routine

Self-care

Stewardship

Acute bronchitis (well)No/delayed antibiotic; self-care; safety-net
Low-severity CAP (CRB-65 0)Oral antibiotic at home; review
Persistent coughCXR + NG12 if red flags

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"His CRB-65 is high and he has signs of sepsis — confusion, fast breathing, low oxygen and blood pressure — so this is an emergency admission, with oxygen and treatment started straight away, not tablets at home."

Deductions

Under-triaging sepsis/severe CAP
Over-treating viral bronchitis with antibiotics

Step 3

Examination — Observations/NEWS2 · Chest Signs · Confusion · Hydration

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Examination quantifies severity (full observations / NEWS2, oxygen saturations), localises the infection (focal chest signs of consolidation vs the diffuse wheeze of COPD vs a clear chest in bronchitis), and assesses confusion and hydration — the markers that decide disposition.

📊 Severity

Check	Why
Full observations / NEWS2	RR, SpO2, HR, BP, temp, consciousness — severity/sepsis (Brian: RR 28, SpO2 90%, HR 112, BP 104/62, 38.6°C, confused).
Oxygen saturations	Hypoxia; care with targets in COPD.
Confusion / AMTS	CRB-65 'C'; sepsis; atypical presentation.
Hydration / perfusion	Dehydration, AKI risk, shock.

🫁 Chest & cause

Sign	Suggests
Focal crackles / bronchial breathing / dullness	Consolidation = pneumonia (Brian, right base).
Wheeze / prolonged expiration	COPD exacerbation / asthma.
Clear chest, systemically well	Viral bronchitis.
Reduced air entry / hyper-resonance	Effusion / pneumothorax.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Narration that scores

"I'll take a full set of observations including his oxygen level, check how alert he is, and listen to his chest for signs of pneumonia — these tell me how serious this is and where it needs treating."

Deductions

Not taking full observations / SpO2 / NEWS2
Not assessing confusion or hydration

Step 4

Investigations — Often Clinical · CXR · Bloods/CRP · Resolution & NG12

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Mild bronchitis needs no tests; pneumonia/severe disease needs a chest X-ray and bloods (often as part of admission); CRP can support antibiotic decisions in uncertain primary-care cases; and persistent/non-resolving disease needs a CXR and the NG12 pathway plus a resolution film.

🩻 Acute

Test	When
None	Well patient, clear chest, viral picture — clinical diagnosis.
Chest X-ray	Suspected pneumonia, diagnostic doubt, severe/non-resolving (usually via admission for severe cases).
Bloods (FBC, U&E, CRP, glucose, blood cultures)	Severity, AKI/sepsis, source — with admission (Brian).
CRP (point-of-care)	Can guide antibiotic decisions in uncertain LRTI in primary care.
SpO2 / ABG	Hypoxia; CO2 retention in COPD.

🔬 Follow-up / persistent

Test	Why
Resolution CXR (~6 weeks)	After pneumonia in smokers/over-50s — exclude underlying cancer.
CXR + NG12 pathway	Persistent cough/haemoptysis/weight loss, smoker 40+.
Sputum / TB tests	Persistent productive cough, TB risk (cough >3 weeks, night sweats).
Spirometry / COPD review	Once recovered.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"In hospital he'll have a chest X-ray and blood tests to confirm pneumonia and check his kidneys and oxygen. And because he's a long-term smoker, I'll make sure he has a follow-up X-ray once he's better to confirm it's cleared."

Deductions

Reflex tests/antibiotics for viral bronchitis
Not arranging a resolution CXR / NG12 for persistent disease in a smoker

Step 5

Diagnosis — Bronchitis · CAP · COPD Exacerbation · Mimics

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Name the diagnosis and its severity, and hold the mimics that present as "chest infection" — PE, heart failure, lung cancer, TB.

Diagnosis	Discriminating features
Acute bronchitis	Cough ± sputum, clear chest, systemically well — viral, self-limiting.
Community-acquired pneumonia	Focal signs, fever, tachypnoea, hypoxia, systemic upset; severity by CRB-65 (Brian = severe + sepsis).
Infective COPD exacerbation	Increased breathlessness/sputum volume & purulence on a COPD background.
Sepsis from a chest source	Systemic dysfunction — confusion, hypotension, hypoxia, low urine output.
Mimics	PE (pleuritic pain, risk factors), heart failure (orthopnoea, oedema), lung cancer/TB (persistent), pneumothorax.

🚩 Severity is the diagnosis that matters

Naming "chest infection" is not enough — the clinically decisive judgement is severity. Brian's formulation is severe community-acquired pneumonia with sepsis in a comorbid older man (COPD, diabetes): confusion, hypoxia, tachypnoea, borderline hypotension, reduced urine output — an emergency admission for oxygen, IV antibiotics and fluids, not an outpatient prescription. After recovery: resolution CXR, COPD optimisation and vaccination.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"Your dad has pneumonia — an infection in the lung — and it's made him seriously unwell, affecting his oxygen and his mind. That's why he needs hospital treatment now rather than tablets at home."

Deductions

Diagnosing "chest infection" without grading severity
Missing PE/heart failure mimics

Step 6

Referral — Emergency Admission · Respiratory/TB · 2WW (NG12)

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Referral is severity- and cause-driven: emergency admission for sepsis/severe CAP/respiratory failure; respiratory or TB services for specific disease; and the NG12 lung-cancer pathway for persistent/suspicious presentations.

Referral	Who / when	Urgency
🔴 Emergency admission	Sepsis, severe CAP, respiratory failure, alternative emergency (Brian).	Same day / 999
Respiratory medicine	Recurrent/non-resolving infection, complex COPD, bronchiectasis, empyema.	Soon
🟣 Lung cancer (2WW / NG12)	Persistent cough/haemoptysis/weight loss, abnormal/non-resolving CXR (smoker 40+).	2WW · NG12
TB service	Suspected TB (cough >3 weeks, night sweats, weight loss, risk factors).	Urgent
Community / virtual ward	Selected moderate cases suitable for supported home/IV care.	As available

🎓 SCA Checkpoint — Step 6Tasks

Decisive action

"I'm arranging an emergency ambulance now — I'll call ahead so they're expecting him, give him oxygen while we wait, and send the details. This is the safest place for him to be treated."

Deductions

Delaying admission of a septic patient
Not arranging NG12/TB pathways for persistent disease

Step 7

Management — Admit & Treat Severe · Stewardship for Mild · Safety-Net · Prevention

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Management spans the spectrum: emergency treatment and admission for sepsis/severe CAP (oxygen, IV antibiotics, fluids); appropriate antibiotics for pneumonia/COPD exacerbation; antibiotic stewardship (no/delayed prescription) with safety-netting for self-limiting bronchitis; and prevention (vaccination, COPD self-management) and follow-up.

7A — Across the spectrum

🚑 Severe / pneumonia / COPD

Element	Detail
Sepsis / severe CAP (Brian)	Oxygen (target sats; care in COPD), IV antibiotics + fluids per sepsis pathway, urgent admission; treat AKI/glucose.
CAP antibiotics	Severity-guided (e.g. amoxicillin first-line low-severity; combination/IV for higher severity) per local guidance.
COPD exacerbation	Increase bronchodilators; oral steroids if more breathless; antibiotics if purulent sputum/criteria; rescue pack & plan.
Oxygen in COPD	Controlled oxygen to target saturation; watch CO2 retention.

💊 Mild & cross-cutting

Element	Detail
Bronchitis — stewardship	No or back-up (delayed) antibiotic; self-care (fluids, analgesia, rest); explain natural history.
Safety-net	Clear advice: seek help if breathless, confused, not improving/worsening, fever persists, poor intake — when and who to call.
Follow-up	Resolution CXR (smokers/over-50s); review recovery; COPD/spirometry review.
Prevention	Flu/pneumococcal/COVID vaccination; smoking cessation; COPD optimisation.
Persistent → investigate	CXR + NG12 / TB if not resolving.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"For your dad: emergency admission now, oxygen and treatment started here. (For a milder patient: 'rest, fluids and a back-up antibiotic to use only if you worsen — and come back urgently if you get breathless or confused.') Once he's recovered we'll arrange a check X-ray, review his COPD and make sure his vaccines are up to date."

Deductions

Oral antibiotics + home for a septic patient
Reflex antibiotics for viral bronchitis with no safety-net
No prevention/follow-up; missing resolution CXR in a smoker

"Dad's had a chest infection for a few days — cough, fever, getting breathless — and since yesterday he's gone really confused and wobbly. I just thought he needed some antibiotics, but he's gone downhill so fast."

Who you are (Brian's daughter)

You've brought your dad Brian, 72, who has COPD (ex-smoker, 40 pack-years) and diabetes. He's had 5 days of productive cough, fever and worsening breathlessness, and since yesterday he's confused, unsteady and "not himself". He's barely eaten or drunk and is passing less urine. You expected the GP to give him antibiotics to take at home. You're frightened by how quickly he's changed.

Hidden concerns (reveal if explored)

Fear (main): the confusion scares you — your mum was like that before she died. You're reassured by clear, calm action.

Reluctance about hospital: Dad hates hospitals; you worry about taking him. You accept it when the reason is explained.

Guilt: you wonder if you should have come sooner — needs reassurance you did the right thing.

Clinical details if asked

5 days cough/fever/breathlessness; new confusion and unsteadiness since yesterday
COPD, type 2 diabetes; ex-smoker 40 pack-years; usually independent and "with it"
Poor oral intake; reduced urine output
On exam (you can confirm what the GP finds): looks unwell, breathing fast, low oxygen, fast pulse, fever, confused
Not sure about recent vaccinations

Reactions at key moments

On "he needs hospital, not tablets": initially taken aback ("I thought antibiotics would do it") then accepting when the reasons are explained.
On the confusion being important: relieved it's being taken seriously.
On reassurance you did right bringing him: visibly comforted.
Challenge line: "Can't you just give him some antibiotics to take at home? He really hates hospitals."

"Are you sure he needs to go in? Can't you just give him strong antibiotics to take at home — he'll be so much happier in his own bed."

Resolution: The consultation succeeds if the GP: (1) takes full observations/NEWS2 and screens for sepsis, recognising confusion + hypoxia + tachypnoea + borderline BP + reduced urine output as severe CAP with sepsis (high CRB-65) in a comorbid older man; (2) does NOT prescribe oral antibiotics for home but arranges emergency admission with oxygen and pre-alert; (3) distinguishes this from bronchitis/COPD and explains the diagnosis and plan compassionately to a frightened, reluctant daughter, validating her for bringing him; (4) plans follow-up (resolution CXR given smoking history, COPD review, vaccination). It fails if the GP yields to the "just antibiotics at home" request and sends a septic patient away.

🏥

Clinic Quick Reference

Chest Infections — Clinical Decision Framework

Bronchitis vs pneumonia · CRB-65/sepsis · stewardship

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🚦 1 — Assess severity

Cough / LRTI → observations + chest exam

▼

🔴 Emergency

Sepsis (confusion, RR≥22, ↓BP, hypoxia, ↓urine)
Severe CAP (high CRB-65) / resp failure

O2 + IV abx/fluids + admit

🟠 Moderate

CAP CRB-65 1–2; vulnerable
Infective COPD exacerbation

Treat ± admit

🟢 Mild

Acute bronchitis (well, clear chest)
CAP CRB-65 0

Self-care / oral abx; stewardship

💊 2 — Treat & follow up

Bronchitis: usually viral — no/delayed antibiotic + safety-net. CAP: severity-guided antibiotics (amoxicillin first-line low-severity per local guidance); admit if severe/septic. COPD exacerbation: bronchodilators ± steroids ± antibiotics (purulence); rescue pack; controlled O2. Persistent/non-resolving (smoker 40+, haemoptysis, weight loss) → CXR + NG12 ± TB. Resolution CXR in smokers/over-50s; vaccination & cessation; protect the vulnerable.

🎓

SCA Quick Reference

Chest Infections — Consultation Playbook

Grade severity · spot sepsis · steward antibiotics · safety-net

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🎯 The three pivots that pass this case

1 · Grade severity / sepsis

Observations + CRB-65 + sepsis screen. Confusion/hypoxia/↓BP in a comorbid elder = emergency, not home antibiotics.

2 · Right treatment

Bronchitis = stewardship (no/delayed antibiotic). Pneumonia/COPD = active treatment; severe/septic = admit + O2 + IV.

3 · Safety-net & follow up

Clear warning signs; persistent → CXR/NG12/TB; resolution CXR in smokers/over-50s; vaccinate.

⛔ Don't send a septic/severe-CAP patient home on oral antibiotics · Don't reflex-prescribe antibiotics for viral bronchitis — steward & safety-net · Don't miss atypical severity (confusion/falls) in the elderly · Don't forget persistent symptoms → CXR/NG12/TB and a resolution CXR in smokers/over-50s · Use controlled oxygen in COPD

Chest Infections (LRTI / CAP) · GP Clinical Reasoning Framework v2 · NICE NG138 (pneumonia in adults — community) · NICE CG191 / NG138 · NICE NG114 (cough/antimicrobial) · NICE NG12 (lung cancer) · NICE sepsis (NG51) · COPD (NG115)

Distinguish self-limiting viral bronchitis from pneumonia and COPD exacerbation by examination & systemic features · Stratify CAP with CRB-65 and screen for sepsis (NEWS2) — confusion/RR≥22/hypotension/hypoxia/low urine output = emergency admission · Antibiotic stewardship: no/delayed prescription + safety-net for uncomplicated cases; severity-guided antibiotics when indicated · Controlled oxygen in COPD · Persistent/non-resolving symptoms (smoker 40+, haemoptysis, weight loss) → CXR + NG12 ± TB; resolution CXR in smokers/over-50s; vaccinate & protect the vulnerable

Teaching clinicians why each step matters — not just what to do · Always consult current NICE NG138/NG114/NG12 and sepsis guidance · Clinical judgement takes precedence over any framework

Chest Infections

Red Flags — the chest infection that is an emergency

🏥 Reframing to admission

💊 Stewardship (milder cases)

👪 Supporting the family

🛡️ Prevention

Same day / 999

Treat ± admit

Self-care

🚩 Severity is the diagnosis that matters

🎭 Patient actor brief — click to practise (the daughter)

Who you are (Brian's daughter)

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments