Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in. 

 The NP is seeing a 65-year-old woman who is a former smoker, having quit at age 40, with a 20 pack-year cigarette smoking history, and has been diagnosed with community-acquired pneumonia (CAP). Which of the following is most often noted CAP finding in an adult who is deemed to be appropriate for outpatient treatment?  
 
A. Pleuritic chest pain 
 
B. Dyspnea 
 
C. Purulent sputum production 
 
D. Cough 

 Well, correct answer here is actually D; but, let's take a look at this question because this is one of those situations where you are truly picking the best answer and not just the correct answer, because technically all four are correct or, at least possible findings.

Where do we start then?  

 Let's determine what kind of a question this is. This is an assessment question. Though we are given the diagnosis of community acquired pneumonia, often abbreviated as simply CAP, we're being asked to identify the most often noted finding in this condition. Once again, it's important to look at every single word in the question, and we're being asked to choose the most universally found clinical finding in community acquired pneumonia. Knowing the most common findings in each clinical situation is critical to appropriate diagnosis and treatment.  

 Let's take a look at the background information in this scenario. We're told that she's been diagnosed with community acquired pneumonia, although we're not given vital signs or other information on her clinical presentation. We're not being told what her respiratory rate is, what her chest exam reveals, etc. While it's tempting to say yes, but we need more data, if the question states that she has CAP, then she has CAP. Simply assume it's the correct diagnosis. Also assume it, since we're being told she's going to be treated as an outpatient, she is stable enough with non deranged vital signs, intact mental status, and able to keep down fluids, that that's all true. And she will be, in fact, safe for outpatient care.  

 As an RN, you've likely seen many ill, very ill indeed critically ill people with community acquired pneumonia. At the same time, for people age 65 years and older, only 2% of that group with CAP require hospitalization. In other words, as is often the case with RN practice, you in the hospital see the sickest of the sickest of the sick.  

 What is pneumonia? Most often caused by bacterial or viral infection, Pneumonia is an acute lower respiratory tract infection involving the lung parenchyma, interstitial tissues, and alveolar spaces. This differs from bronchitis, where implied in that diagnosis, only the bronchi are involved. The term community acquired pneumonia is used to describe the onset of disease in a person who resides within the community, not in a nursing home or other care facility with no recent less than two weeks in the recent past hospitalization. What that tells you is the likelihood of her having some resistant or unusual pathogen is way, way down. That's the rule in treating community acquired pneumonia.  

 The patient mentioned in the question is an older adult with a significant past history of tobacco use, but not present history of this use. While the cigarette smoking history could lead the NP to think about a concomitant COPD diagnosis that could complicate this scenario, given we're not informed that she has COPD, we should not assume she does. Please note, she quit more than 20 years ago which has definitely limited the possibility of the progressive airway damage seen in people of her age who continue to smoke. In addition, most but certainly not all people with COPD, have a greater than 40 pack year cigarette smoking history. Hers was only 20 pack years.  

 Let's take a look at the answers to the question provided: 

 A. Pleuritic chest pain.  

What is pleuritic chest pain? This is chest pain characterized by a localized, sudden and intense, sharp stabbing or burning pain in the chest when inhaling and exhaling. It is reported in about one half of people with pneumonia. Well, as I said earlier, technically then pleuritic chest pain is right, but we've been asked to choose the most common finding, therefore, what I'm going to do is say let's take a look at other choices there.  

 B. Dyspnea or shortness of breath, sometimes even referred to as air hunger or difficulty breathing, breathlessness, is reported in about two thirds of patients with CAP, who can be treated as outpatients. The rate is likely higher in patients whose CAP is severe enough to warrant hospitalization. Again, that's going to be the scenario most common in the person transitioning from the RN to the NP role. So, two thirds is better than one half. But I want to look for something that's even greater than two thirds.

C. Purulent sputum production. 

 While widely considered to be a nearly universal finding in pneumonia, sputum production is reported in only about two thirds of all people with this condition, most often with pneumonia caused by a viral or an atypical pathogen, and two, the more common atypical pathogens would be M pneumonia and C pneumonia — There is little to no sputum production. While pneumonia caused by streptococcus pneumoniae and other common respiratory pathogens, is more likely to cause sputum production. Also, as previously mentioned, do not automatically assume the patient has COPD because a smoking history where sputum production is common and often daily. One more time, don't assume anything that you haven't been told in an exam question.  

Last option is cough. This is our correct answer. More than 90% of people with pneumonia will have persistent cough. And in fact, that's often what drives them in for care, more than feeling short of breath, more than producing sputum, etc. Consider what happens when we cough under any circumstances, whether it's pneumonia or not. What happens is you take a deep breath in, close the glottis, that increases the pressure within the airways, and that increased pressure helps clear it and potentially open the airways. Given that there is airway inflammation in irritation with pneumonia, regardless of its causative pathogen, cough will be nearly a universal finding in pneumonia. The cough is often dry with pneumonia caused by the atypical or viral pathogens, and is more likely to be congested or what is sometimes colloquially called a wet cough with other common gram positive and gram negative community acquired pneumonia organisms.  

 Key takeaway: In common conditions such as pneumonia, many clinical findings can be reported. Knowing which are the most common will help better inform your clinical decision making process.  

 Thank you for listening to NP Certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast. And for more NP resources, visit FHEA.com.