HISTORY. Ask about malaise, aching muscles, anorexia, headache, high fever, or recurrent chills. Establish a history of chest pain or coughing, which begins as a nonproductive cough but eventually becomes productive. Ask the patient about gastrointestinal symptoms such as diarrhea, nausea, and vomiting. Because the central nervous system is involved in about 30% of cases, ask the family or significant others if the patient has experienced recent confusion or decreased level of consciousness.

Determine if the patient has been close to a river, lake, or stream, which might have resulted in possible exposure to the bacteria. Establish a work history of employment at an excavation site or water distribution center, in a cooling tower, or near an evaporative condenser. Ask if the patient works or lives in a facility with central air conditioning or humidifiers. Ask if the patient has used a respiratory apparatus or a nasogastric tube in the recent past.

PHYSICAL EXAMINATION. The patient usually appears acutely ill, with a high fever. Note any neurological signs, such as altered level of consciousness, confusion, or coma. Inspect the patient's sputum, which may be grayish or rust-colored, nonpurulent, and occasionally, blood-streaked. Note the respiratory rate, which may be rapid and accompanied by dyspnea.

Auscultate the breathing; fine or coarse crackles may be audible, depending on the stage of the disease process. Auscultate the blood pressure and heart rate; note that some patients develop severe hypotension and bradycardia. Percuss the chest for dullness over areas of secretions and consolidation or pleural effusions. Palpate the peripheral pulses to determine strength.

PSYCHOSOCIAL. A previously healthy person with a possible minor upper respiratory infection is at risk for life-threatening complications, such as multiple organ failure. Assess the patient's ability to cope with a sudden illness. Assess the patient's level of anxiety and fear.

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