EXAM: CTA chest, PE protocol
CLINICAL INDICATION: Pleuritic R chest pain, tachycardia, D-dimer 2.40.
TECHNIQUE: Helical CT of the chest after 75 mL Omnipaque 350 IV, pulmonary arterial phase. Axial, coronal and sagittal reformats.
PRELIMINARY REPORT (overnight teleradiology)
FINDINGS: Dense airspace consolidation in the right lower lobe with air bronchograms. Remaining lungs clear. No pleural effusion. Main and lobar pulmonary arteries opacify well without filling defect. Heart size normal. No pericardial effusion. No mediastinal adenopathy.
IMPRESSION:
1. Right lower lobe consolidation, consistent with pneumonia.
2. No pulmonary embolism.
Final interpretation to follow by staff radiologist.
CC: Cough, fever, right-sided chest pain x4 days.
HPI: 67F with HTN, HLD, hypothyroidism and obesity presents with 4 days of productive cough (rust-colored sputum), subjective fevers, rigors and R-sided pleuritic chest pain worse with deep inspiration. Mild DOE. Drove 9 hrs each way to visit grandchildren 2 wks ago. Denies leg swelling, calf pain, hemoptysis. Never smoker. No recent hospitalization or abx.
ROS: + fatigue, poor appetite. Neg for abd pain, dysuria, rash.
Vitals: T 38.6 C, HR 108, BP 138/82, RR 22, SpO2 93% RA.
Exam: Ill-appearing, mildly tachypneic, speaking full sentences. Crackles and bronchial breath sounds R base. Tachycardic, regular. Calves soft, nontender, no edema.
Labs: WBC 16.2 (88% PMN), Hgb 12.9, Plt 302. Na 137, K 4.0, BUN 18, Cr 0.9, Glu 128. Lactate 1.6. Procalcitonin 1.8. Troponin <0.01. D-dimer 2.40 (ref <0.50). Blood cx x2 sent.
CXR: RLL airspace opacity.
MDM: Pleuritic pain + tachycardia + long car trip + elevated D-dimer -> CTA chest obtained. Prelim read: RLL consolidation, no pulmonary embolism.
Assessment/Plan:
1. Community-acquired pneumonia, RLL. CURB-65 = 1. Ceftriaxone 1 g IV and azithromycin 500 mg IV given after cultures.
2. Pleuritic chest pain - PE ruled out by CTA (prelim). Likely pleuritic from pneumonia.
3. HTN - home meds.
Dispo: Admit to hospitalist service for IV abx and O2 monitoring.
HISTORY AND PHYSICAL
HPI: 67F admitted from ED with 4 days of productive cough, fever and R pleuritic chest pain. See ED note. Feels "wiped out." No orthopnea.
PMH: HTN, hyperlipidemia, hypothyroidism, obesity.
Meds: lisinopril 20 mg daily, atorvastatin 40 mg qHS, levothyroxine 88 mcg daily.
Allergies: NKDA.
Social: Retired teacher, lives with husband. Never smoker, rare EtOH.
Exam: T 38.1, HR 102, BP 132/78, RR 20, SpO2 94% on 2 L NC. BMI 33.4. Crackles R base, egophony RLL. RRR. Abd soft. No LE edema.
Data: WBC 16.2, procalcitonin 1.8, Cr 0.9. CXR RLL opacity. CTA chest (prelim): RLL consolidation, no PE.
Assessment/Plan:
1. Community-acquired pneumonia, RLL - continue ceftriaxone 1 g daily + azithromycin 500 mg daily. F/u blood cx, sputum cx, urine Legionella/strep Ag. O2 to keep SpO2 >92%.
2. Pleuritic chest pain - attributed to pneumonia; PE excluded on CTA. Acetaminophen, incentive spirometry.
3. Hypertension - continue lisinopril.
4. Hyperlipidemia - continue atorvastatin.
5. Hypothyroidism - continue levothyroxine; TSH 2.1 in 06/2026.
6. Obesity, BMI 33.4 - counseled.
VTE ppx: enoxaparin 40 mg SC daily. Code: Full.
ADDENDUM - CTA CHEST, PE PROTOCOL, 09/14/2026 (FINAL INTERPRETATION)
On staff over-read of the preliminary teleradiology interpretation, there are small eccentric filling defects within the segmental arteries of the right lower lobe posterior basal and lateral basal segments, consistent with acute pulmonary emboli. These were not described on the preliminary report. RV/LV ratio 0.8; no CT evidence of right heart strain. Remaining findings unchanged: right lower lobe consolidation consistent with pneumonia.
REVISED IMPRESSION:
1. Acute segmental pulmonary emboli, right lower lobe. No right heart strain.
2. Right lower lobe pneumonia.
Discrepancy communicated by telephone to Dr. L. Moreno at 09:45 on 09/15/2026; read-back confirmed.
HOSPITAL DAY 2
S: Breathing a little easier. Still pleuritic pain R side with deep breath. Tmax 37.9 overnight. Tolerating diet.
O: T 37.4, HR 96, BP 128/76, RR 18, SpO2 95% on 1 L NC. Crackles R base, improved. Calves nontender.
Labs: WBC 12.4. Cr 0.8. Troponin <0.01, BNP 64. Blood cx NGTD x24 h. Urine Legionella and pneumococcal Ag negative.
Radiology called this AM with an addendum to the admission CTA: segmental filling defects RLL (see report). BLE venous duplex today: no DVT.
Assessment/Plan:
1. Acute segmental pulmonary embolism, right lower lobe - present on the admission CTA, missed on prelim read. Hemodynamically stable, no RV strain on CT, troponin/BNP normal; sPESI 0. Stop enoxaparin ppx. Start apixaban 10 mg BID x7 days, then 5 mg BID. Minor transient risk factor (prolonged car travel); plan at least 3 months anticoagulation. Discussed with patient and husband, questions answered.
2. Community-acquired pneumonia, RLL - improving. Continue ceftriaxone/azithromycin (day 2).
3. HTN, HLD, hypothyroidism - stable on home meds.
Dispo: anticipate d/c in 48-72 h once off O2.
DISCHARGE SUMMARY
Admit: 09/14/2026 Discharge: 09/18/2026 Disposition: Home with husband
DISCHARGE DIAGNOSES:
1. Community-acquired pneumonia, right lower lobe
2. Acute segmental pulmonary embolism, right lower lobe, on apixaban
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Obesity, BMI 33.4
HOSPITAL COURSE:
67F presented with 4 days of cough, fever and R pleuritic chest pain. CXR and CTA showed RLL consolidation. Treated with ceftriaxone and azithromycin; afebrile >48 h by HD3 and weaned to room air 09/17. Transitioned to oral cefpodoxime to complete 7 days total. On HD2, radiology issued an addendum to the admission CTA identifying acute segmental emboli in the RLL. LE duplex negative for DVT. Started apixaban 09/15 and tolerated without bleeding.
PERTINENT RESULTS:
Blood cultures 09/14: no growth at 4 days. Sputum: normal respiratory flora. Urine Legionella/pneumococcal Ag negative.
IMAGING:
- CXR 09/14: RLL airspace opacity.
- CTA chest 09/14: RLL consolidation. No pulmonary embolism.
- BLE venous duplex 09/15: No DVT.
DISCHARGE MEDICATIONS:
- Apixaban 10 mg BID through 09/21, then 5 mg BID
- Cefpodoxime 200 mg BID x3 more days
- Lisinopril 20 mg daily, atorvastatin 40 mg qHS, levothyroxine 88 mcg daily (unchanged)
FOLLOW-UP: PCP in 1 week. Anticoagulation planned for at least 3 months; reassess at 3-month visit. Return for bleeding, worsening SOB or chest pain.