Bulging fissure sign in x ray seen in klebsiella. image shows bulging fissure sign Clinical features Pneumonia, paicularly lobar pneumonia, usually presents as an acute illness. Systemic features, such as fever, rigors, shivering and malaise, predominate and delirium may be present. The appetite is invariably lost and headache frequently repoed. Pulmonary symptoms include cough, which at first is characteristically sho, painful and dry, but later is accompanied by the expectoration of mucopurulent sputum. Rust-coloured sputum may be produced by patients with Strep. pneumoniae infection and the occasional patient may repo haemoptysis Pleuritic chest pain may be a presenting feature and on occasion may be referred to the shoulder or anterior abdominal wall. Upper abdominal tenderness is sometimes apparent in patients with lower lobe pneumonia or those with associated hepatitis. Less typical presentations may be seen in the very young and the elderly. While different organisms often give rise to a similar clinical and radiological picture, it may be possible to infer the likely agent from the clinical context. Mycoplasma pneumoniae is more common in young people and rare in the elderly, whereas Haemophilus influenzae is more common in the elderly, paicularly if underlying lung disease is present. Legionella pneumophila occurs in local outbreaks centred on contaminated cooling towers in hotels, hospitals and other industries. Staph. aureus is more common following an episode of influenza. Klebsiella pneumonia has a specific association with alcohol abuse and often presents with a paicularly severe bacteraemic illness. Recent foreign travel raises the possibility of infections that may otherwise be unusual in the UK, e.g. MERS-coronavirus (Middle East ), melioidosis caused by Burkholderia pseudomallei (South-east Asia and nohern Australia and endemic fungal infection (Noh, Central or South America. Ceain occupations) may be associated with exposure to specific bacteria . Clinical examination should first focus on the respiratory and pulse rates, blood pressure and an assessment of the mental state, as these are impoant in forming a judgement as to severity of the illness . Chest signs vary, depending on the inflammatory response, which proceeds through stages of acute exudation, red and then grey hepatisation, and finally resolution. When consolidated, the lung is typically dull to percussion and, as conduction of sound is enhanced, auscultation reveals bronchial breathing and whispering pectoriloquy; crackles are heard throughout. An assessment of the state of nutrition is impoant, paicularly in the elderly. The presence of herpes labialis may point to streptococcal infection, as may the finding of 'rusty' sputum. Ref Davidson edition23rd pg 585