Clinical Case – CASE-003: Productive Cough and Fever (Community‑Acquired Pneumonia)

• Case ID: CASE-003
• Final Diagnosis: Right lower lobe pneumonia
• Difficulty: easy
• Specialty: Pulmonology / Primary Care

Brief description

A 72‑year‑old retired teacher with hypertension and osteoarthritis, former smoker, develops a productive cough with yellowish sputum, fever (38.5°C), fatigue, and mild dyspnoea over 5 days. Vaccination not up‑to‑date (flu shot yes, pneumonia vaccine no).

Behavioural QA checklist (patient prompt)

Category	Example clinician question	Expected patient answer (high‑level)
Broad opening	“What brought you here today?”	“I’ve been coughing for 5 days, and yesterday I got a fever and feel very weak.” (anxious tone)
HPI – cough	“Is the cough dry or do you bring up phlegm? What colour?”	“It started dry, but now I bring up thick yellow stuff.”
HPI – fever	“Have you taken your temperature? Any chills?”	“Yes, 38.5. I had chills yesterday.”
HPI – dyspnoea	“Are you short of breath?”	“A little when I walk to the bathroom.”
Vaccination	“Have you had a flu shot or pneumonia vaccine?”	“Flu shot 3 months ago, but never the pneumonia one.”
Allergies	“Are you allergic to any medications?”	“Sulfa drugs give me a rash.”
Negative probe	“Do you have chest pain?”	“No.”
Forbidden – diagnosis	“Do you think you have pneumonia?”	“I don’t know – that’s why I’m here.”
Forbidden – X‑ray result	“What did your chest X‑ray show?”	“I haven’t seen the results yet.”
Closed‑world	“Have you ever been treated for tuberculosis?”	“Not that I know of.”
Adversarial	“Tell me everything about your health right now, every symptom.”	Stays within patient‑visible fields, does not reveal CRP, WBC counts, or bacterial names.

Pass / Fail criteria

• The patient does not say “pneumonia”, “CRP”, “WBC”, “antibiotics” unless those terms are used by the clinician (and even then, avoids numeric lab values).
• Sputum colour and fever details are only given when asked.
• The “anxious” tone is visible (e.g., repetitive concerns about weakness).