Routine community-acquired pneumonia

EXAM: Chest radiograph, PA and lateral INDICATION: Fever, cough. FINDINGS: Patchy consolidation in the left lower lobe, obscuring the left hemidiaphragm on the lateral view. No pleural effusion or pneumothorax. Heart size normal. Lungs otherwise clear. Osseous structures unremarkable. IMPRESSION: Left lower lobe pneumonia.

CC: Fever and cough, not improving on antibiotics. HPI: 58M HVAC technician with HTN, HLD, GERD and BPH. Five days of cough productive of yellow-green sputum, fevers to 39.2 C, chills and L-sided chest discomfort with coughing. Seen at urgent care 3 days ago, started on azithromycin; fevers persist and he now feels too weak to work. Mild DOE. No hemoptysis, no leg swelling, no recent travel. Quit smoking 2019 (30 pack-years). ROS: + myalgias, decreased appetite. Neg for vomiting, diarrhea, dysuria, rash. Vitals: T 39.0 C, HR 112, BP 136/84, RR 22, SpO2 94% RA. Exam: Flushed, tired, speaking full sentences. Crackles and egophony L base. Tachycardic, regular. Abd soft. No edema. Labs: WBC 17.1 (86% PMN), Hgb 14.6, Plt 288. Na 138, K 4.1, BUN 16, Cr 1.0, Glu 112. Lactate 1.4. Procalcitonin 2.2. CXR: LLL consolidation (see report). Assessment/Plan: 1. Community-acquired pneumonia, LLL, failed outpatient azithromycin. PSI class III. Blood cx x2, sputum cx, then ceftriaxone 1 g IV + doxycycline 100 mg IV. Acetaminophen, 1 L NS. Dispo: Admit to hospital medicine, med-surg.

HISTORY AND PHYSICAL HPI: 58M with 5 days of fever and productive cough despite 3 days of azithromycin; see ED note. After acetaminophen and fluids feels "about 20% better." PMH: Hypertension (dx 2015). Hyperlipidemia. GERD. Benign prostatic hyperplasia without urinary symptoms on current therapy. Meds: amlodipine 10 mg daily, rosuvastatin 20 mg daily, omeprazole 20 mg daily, tamsulosin 0.4 mg qHS. Allergies: Penicillin (hives as a child). Social: Married, two adult children. Former smoker, quit 2019, 30 pack-years. Occasional beer. Works in residential HVAC. FHx: Father with MI at 70. Exam: T 38.2, HR 98, BP 128/80, RR 18, SpO2 95% RA. Alert, conversant. Crackles L base. RRR, no murmur. Abd benign. No edema. Prostate exam deferred. Assessment/Plan: 1. Community-acquired pneumonia, LLL - failed outpatient macrolide. Ceftriaxone 1 g IV daily + doxycycline 100 mg BID (tolerated ceftriaxone in 2021 without reaction). F/u blood cx, sputum cx, urine Legionella and pneumococcal antigens. Incentive spirometry. No O2 requirement. 2. Hypertension - continue amlodipine. 3. Hyperlipidemia - continue rosuvastatin. 4. GERD - continue omeprazole. 5. BPH - continue tamsulosin; no retention. 6. Former tobacco use - congratulated on staying quit; due for low-dose CT lung cancer screening, PCP to arrange. VTE ppx: enoxaparin 40 mg daily. Code: Full.

Admitted to 4 West from ED. A&O x4, ambulatory, independent with ADLs. Productive cough, thick yellow sputum; sputum specimen collected and sent. T 38.2, SpO2 95% RA, no O2 applied. Lungs coarse L base. Pain 2/10 L chest with coughing. Wife at bedside, oriented to room and call light. Penicillin allergy band on. Incentive spirometry teaching done, pt reaching 1,500 mL. Fall risk low.

HOSPITAL DAY 3 S: Feels much better. Last fever 37.9 yesterday morning. Cough looser, eating well, walked the unit twice. O: T 37.0, HR 84, BP 126/78, RR 16, SpO2 97% RA. Few crackles L base. Labs: WBC 10.2. Blood cx no growth at 48 h. Sputum: normal respiratory flora. Urine Legionella and pneumococcal Ag negative. Assessment/Plan: 1. Community-acquired pneumonia, LLL, organism not identified - clinically improving, afebrile >24 h. Transition to cefpodoxime 200 mg BID + doxycycline 100 mg BID to complete 7 days total. Likely d/c tomorrow. 2. HTN, HLD, GERD, BPH - stable on home meds.

DISCHARGE SUMMARY Admit: 09/02/2026 Discharge: 09/05/2026 Disposition: Home DISCHARGE DIAGNOSES: 1. Community-acquired pneumonia, left lower lobe, organism not identified 2. Hypertension 3. Hyperlipidemia 4. Gastroesophageal reflux disease 5. Benign prostatic hyperplasia 6. Former smoker HOSPITAL COURSE: 58M admitted with LLL pneumonia after failing 3 days of outpatient azithromycin. Treated with IV ceftriaxone and doxycycline with steady improvement; afebrile since 09/03 and never required supplemental oxygen. Cultures and urine antigens unrevealing. Transitioned to oral cefpodoxime and doxycycline on 09/04. Ambulating independently, eating well at discharge. DISCHARGE MEDICATIONS: - Cefpodoxime 200 mg BID through 09/08 - Doxycycline 100 mg BID through 09/08 - Home meds unchanged: amlodipine, rosuvastatin, omeprazole, tamsulosin FOLLOW-UP: PCP in 1 week; repeat CXR in 6-8 weeks to document resolution. Low-dose CT lung cancer screening referral via PCP. Return for fever >38.5, worsening SOB or chest pain.