Diagnosis is not always straightforward as pneumonia has some symptoms in common with other respiratory conditions such as the common cold, bronchitis or asthma.9

Typical symptoms include:9,11

·       a cough – dry or productive with discoloured mucus

·       breathing difficulties (eg rapid/shallow breathing and/or breathlessness when resting)

·       tachycardia

·       fever, sweating and/or shivering

·       general malaise

·       appetite loss

·       chest pain on breathing/coughing.

Pain on breathing is likely due to pleurisy, an infection and resultant inflammation of the pleura, the thin outer covering of the lung under the ribcage.12

Less common symptoms include coughing up blood (haemoptysis), headache, tiredness, gastric upset, and musculoskeletal pain. Confusion or disorientation is possible especially in the elderly. Rare complications include septicaemia (requiring urgent attention) and also lung abscesses, usually due to a serious pre-existing illness or chronic alcohol misuse.9

Patients should seek urgent medical attention if there is rapid breathing, pain on breathing or confusion.

NICE’s 2014 clinical guidance CG191 ‘Pneumonia in adults: diagnosis and management’ allows GPs to make a CAP diagnosis on presenting symptoms including listening to the chest, but without a chest x-ray. In a hospital setting, diagnosis will usually be confirmed with a chest x-ray.6,9

GPs are advised to assess CAP severity using the CRB65 score, calculated by giving 1 point for each of the following prognostic features:6

·       confusion/disorientation

·       a breathing rate of 30 breaths per minute or more

·       low blood pressure with diastolic 60 mmHg or less, or systolic below 90 mmHg

·       aged 65 or older.

Patients scoring zero represent a fatality risk below 1%, so home care is suitable, but hospital assessment should otherwise be considered. A high risk score of 3 or 4 indicates a mortality risk above 10% with the possibility of intensive care being needed.

Patients with low severity CAP would not normally be offered a microbiological test, but with medium to high severity NICE recommends blood and sputum cultures as well as considering pneumococcal and legionella urinary antigen tests.