Situation: A 72-year-old woman is brought from home to the emergency room with fever, productive cough, and right-sided pleuritic chest pain for 2 days. A chest X-ray shows consolidation of the right lower lobe. She has hypertension controlled with amlodipine and has no known drug allergies. Her findings are: alert and oriented to time, place, and person; respiratory rate 31/min; blood pressure 104/58 mmHg; heart rate 108/min; blood urea nitrogen (BUN) 18 mg/dL (urea 6.4 mmol/L). What is her CURB-65 score?

CURB-65 gives 1 point each for confusion, urea above 7 mmol/L (BUN above 19 mg/dL), respiratory rate of 30/min or more, systolic pressure below 90 mmHg or diastolic pressure of 60 mmHg or less, and age 65 years or older. She scores for respiratory rate (31/min), diastolic pressure (58 mmHg), and age (72 years), for a total of 3. She is not confused, her BUN is below the cut-off, and heart rate is not part of the score.

Scoring the CURB-65

The CURB-65 tool assigns 1 point for each of five findings present at initial assessment. The components are Confusion, Urea (blood urea nitrogen), Respiratory rate, Blood pressure, and Age ≥65 years. A higher total score indicates greater mortality risk and guides decisions about outpatient management, hospital admission, or intensive care.

For this patient, each criterion is evaluated against the defined thresholds.

CURB-65 component	Cut-off for 1 point	Patient value	Point assigned
Confusion	New disorientation or AMS	Alert and oriented x3	0
Urea (BUN)	Urea >7 mmol/L (BUN >19 mg/dL)	BUN 18 mg/dL (urea 6.4 mmol/L)	0
Respiratory rate	≥30/min	31/min	1
Blood pressure	SBP <90 mmHg or DBP ≤60 mmHg	104/58 mmHg (DBP 58)	1
Age	≥65 years	72 years	1

The total is 3. She earns points for tachypnea, diastolic hypotension, and age, but not for confusion or urea elevation. Heart rate is not a component of CURB-65 and therefore does not contribute to the score.

Key point! The blood pressure criterion is met if either the systolic OR the diastolic value crosses its threshold. A diastolic pressure of 58 mmHg is ≤60 mmHg, so it scores even though the systolic pressure of 104 mmHg is normal. This is a common source of under-scoring in clinical practice.

Watch out! The urea threshold in CURB-65 is 7 mmol/L, which corresponds to a BUN of approximately 19–20 mg/dL. The patient’s BUN of 18 mg/dL is just below the cut-off, so no point is given. Do not round up or apply a “near-miss” interpretation.

The CURB-65 score is used to stratify mortality risk in community-acquired pneumonia and to support decisions about the appropriate level of care. A score of 3 places this patient in the high-risk group, where inpatient management is generally indicated and assessment for possible intensive care should be considered. The score reflects the combined burden of respiratory compromise, hemodynamic vulnerability, and advanced age, all of which independently predict poorer outcomes in pneumonia.