Diagnostic process: Doctor, I don´t feel well

I met my patient, a 65-years-old man with a diagnosis of colon cancer without residual tumor, and diabetes type 2. He was on his third day in the hospital after a diagnosis of pneumonia. I said to him:you are going home tomorrow, but he said to me : doctor I don´t feel well…

CLINICAL EVOLUTION: I had in my mind the clinical pattern of a favourable evolution of a pneumonia treated with a cephalosporin. But something was not normal: the patient referred dyspnea while walking and his oxygen saturation was under 90%. My gut feeling says to me that this evolution with dyspnea and the persistence of fever was not normal. I asked for a Angio CAT scan to rule-out a pulmonary embolism. After the scan I obtained the explanation for the persistence of the clinical symptoms.

COMMENTS: The diagnostic is a process and there is usually time to recalibrate the first impression and decision. When the clinical evolution is not the expected, the clinician must be aware about an atypical presentation. In this case the persistence of fever even with an effective antibiotic treatment was associated with the presence of a pulmonary abscess, an infectious complication with a more difficult response to the antibiotics. The patient is usually correct about his body problems.