Pneumonia with a history of blood clots

EXAM: Chest radiograph, PA and lateral INDICATION: Cough, fever. FINDINGS: Airspace opacity in the left lower lobe. No pleural effusion. Heart size normal. Pulmonary vasculature normal. IMPRESSION: Left lower lobe pneumonia.

CC: Cough and fever x4 days. HPI: 61F with HTN, hypothyroidism, HLD, GERD and history of DVT/PE presents with productive cough, fever to 38.9 C and malaise. Mild DOE. No chest pain, hemoptysis, or leg swelling. History of R femoral DVT and bilateral PE after R total knee replacement in 2022; completed anticoagulation 2023. Vitals: T 38.7, HR 102, BP 142/86, RR 20, SpO2 95% RA. Exam: Crackles L base. Calves symmetric, nontender, no edema. R knee well-healed scar. Labs: WBC 14.9, Hgb 13.2, Cr 0.8, Na 139. Lactate 1.2. CXR: LLL infiltrate. MDM: PE considered given prior VTE, but presentation, focal exam and CXR consistent with pneumonia; no pleuritic pain, no leg findings. CTA not indicated at this time. Assessment/Plan: 1. Community-acquired pneumonia, LLL - ceftriaxone + azithromycin. Admit.

HISTORY AND PHYSICAL HPI: See ED. Unable to keep up with oral fluids and too fatigued to manage at home. PMH: HTN. Hypothyroidism. HLD. GERD. History of R femoral DVT and bilateral PE (provoked, post-op, 11/2022) - completed 6 months of rivaroxaban 05/2023, no recurrence, no longer on anticoagulation. S/p R TKA 11/2022. Meds: losartan 50 mg daily, levothyroxine 100 mcg daily, pravastatin 40 mg daily, pantoprazole 40 mg daily. Exam: T 38.2, HR 96, BP 134/80, SpO2 95% RA. Crackles LLL. No calf tenderness. Assessment/Plan: 1. Community-acquired pneumonia, LLL - ceftriaxone 1 g + azithromycin 500 mg daily; cultures pending. 2. History of DVT/PE - completed anticoagulation 2023; no signs of current VTE. Enoxaparin 40 mg daily for prophylaxis. 3. HTN - continue losartan. 4. Hypothyroidism - levothyroxine. 5. HLD - pravastatin. 6. GERD - pantoprazole. 7. S/p R TKA - ambulating independently.

Pt resting, cough productive of small amounts of yellow sputum. Afebrile this shift, SpO2 96% RA. Enoxaparin 40 mg SC given at 21:00 for VTE prophylaxis. Pt asked why she is getting "blood thinner shots" again; explained this is preventive while she is less active. Pt states she had clots after her knee surgery in 2022 and "finished the pills a long time ago." Calves soft, no swelling or pain. Ambulated to bathroom independently.

HOSPITAL DAY 3 S: Afebrile since yesterday AM, cough improving, eating well. O: T 36.9, HR 80, BP 128/78, SpO2 97% RA. Few crackles L base. Labs: WBC 9.8. Blood cx no growth at 48 h. Assessment/Plan: 1. CAP, LLL - improving; switch to cefpodoxime PO + complete azithromycin. 2. History of DVT/PE - VTE ppx continues while inpatient. 3. HTN, hypothyroidism, HLD, GERD - stable. Plan d/c tomorrow.

DISCHARGE SUMMARY Admit: 09/21/2026 Discharge: 09/24/2026 Disposition: Home DISCHARGE DIAGNOSES: 1. Community-acquired pneumonia, left lower lobe 2. Hypertension 3. Hypothyroidism 4. Hyperlipidemia 5. GERD 6. History of DVT/PE (2022), completed anticoagulation 2023 7. Status post right total knee arthroplasty HOSPITAL COURSE: Treated with ceftriaxone/azithromycin, improved quickly, never needed oxygen. Transitioned to cefpodoxime to complete 5 days. Received enoxaparin prophylaxis while inpatient; no anticoagulation indicated at discharge. Encouraged ambulation. DISCHARGE MEDICATIONS: cefpodoxime 200 mg BID x2 days; home meds unchanged. FOLLOW-UP: PCP 1-2 weeks.