CC: fever, productive cough x3 days.
HPI: 74F with HTN, T2DM (metformin), HLD, GERD presents with 3 days of cough productive of rust-colored sputum, fevers to 102F at home, R-sided pleuritic chest pain, and generalized weakness. Decreased PO intake x2 days. No sick contacts. No recent hospitalization or antibiotics.
ROS: + fever, chills, cough, pleuritic CP, fatigue. Denies hemoptysis, abd pain, dysuria, diarrhea, rash.
Vitals: T 39.0C, HR 114, RR 24, BP 112/66, SpO2 93% RA.
Exam: Ill-appearing, dry MM. Crackles and bronchial breath sounds R base. RRR, tachycardic. Abd soft, NT. No CVA tenderness. Skin warm, no mottling. A&O x3.
Labs: WBC 17.6 (88% PMN, 9% bands), Hgb 12.8, Plt 241. Na 136, K 4.1, Cr 0.9 (baseline 0.8), BUN 22, glucose 214. Lactate 2.3. Procalcitonin 4.1. UA negative.
CXR (my read): RLL consolidation.
MDM: Meets SIRS (fever, HR, RR, WBC) with clear pulmonary source. Concern for sepsis due to RLL CAP. No hypotension, mentating normally. 30 mL/kg LR bolus started, blood cx x2, sputum cx, urine Legionella/pneumococcal Ag. Ceftriaxone 1 g + azithromycin 500 mg IV given.
Dispo: Admit to medicine.
EXAM: XR chest PA/lateral.
INDICATION: Fever, cough.
FINDINGS: Dense airspace consolidation in the right lower lobe with air bronchograms. No pleural effusion. No pneumothorax. Heart size normal. Mild degenerative changes of the thoracic spine.
IMPRESSION: Right lower lobe consolidation compatible with pneumonia in the appropriate clinical setting.
HPI: As per ED. 74F with 3d productive cough, fever, R pleuritic pain. In ED febrile 39.0, HR 114, RR 24, WBC 17.6 with bandemia, lactate 2.3. Received 30 mL/kg LR; repeat lactate 1.4, HR now 96, BP 118/70.
PMH: HTN, T2DM, HLD, GERD.
Meds: lisinopril 20 mg daily, metformin 1000 mg BID, atorvastatin 40 mg qHS, omeprazole 20 mg daily.
Allergies: NKDA. Social: never smoker, lives with husband, independent.
Exam: T 38.4, HR 96, RR 20, BP 118/70, SpO2 94% RA. Crackles R base. Otherwise unremarkable.
Assessment/Plan:
1. Sepsis, suspected, secondary to RLL community-acquired pneumonia, POA. SIRS 4/4, lactate 2.3 cleared with fluids. No end-organ dysfunction: Cr at baseline, mentation intact, normotensive. Continue ceftriaxone + azithromycin. F/u blood/sputum cx.
2. RLL CAP - as above. Incentive spirometry. No O2 requirement.
3. HTN - hold lisinopril tonight given sepsis/fluids, resume when stable.
4. T2DM - hold metformin, SSI. A1c 7.4.
5. HLD - continue atorvastatin.
6. GERD - continue PPI.
DVT ppx: enoxaparin. Code: Full.
S: Feels somewhat better, still coughing. Tmax 38.3 overnight.
O: HR 92, RR 18, BP 124/72, SpO2 95% RA. Crackles R base, improved. WBC 14.1, Cr 0.8, lactate 1.1. Blood cx NGTD at 18h. Urine pneumococcal and Legionella Ag negative.
A/P:
1. Possible sepsis secondary to RLL CAP - hemodynamically improving, lactate normalized. Cultures NGTD; continue IV ceftriaxone/azithro.
2. RLL CAP - as above.
3. HTN - resume lisinopril.
4. T2DM - SSI, glucose 160-190.
5. HLD, GERD - home meds.
S: Afebrile x36h, eating well, ambulating in halls.
O: T 37.1, HR 84, RR 16, BP 128/74, SpO2 96% RA. Few crackles R base. WBC 9.8. Blood cx no growth at 72h. Sputum cx normal oropharyngeal flora.
A/P:
1. Sepsis, likely, due to RLL CAP - resolved physiology. Transition to PO cefpodoxime; azithro course complete.
2. T2DM - resume metformin.
3. HTN, HLD, GERD - stable.
Anticipate discharge tomorrow.
Admit: 09/03/2026 Discharge: 09/07/2026
Discharge diagnoses:
1. Probable sepsis secondary to right lower lobe pneumonia, present on admission
2. Right lower lobe community-acquired pneumonia
3. Hypertension
4. Type 2 diabetes mellitus without complications, on metformin
5. Hyperlipidemia
6. GERD
Hospital course: 74F admitted with fever 39.0, HR 114, RR 24, WBC 17.6 with bandemia, lactate 2.3 and RLL consolidation. Treated with 30 mL/kg fluids and IV ceftriaxone/azithromycin with prompt improvement; lactate cleared. No hypotension or organ dysfunction at any point. Blood cultures no growth (final pending at discharge); sputum normal flora; urinary antigens negative. Clinical picture felt most consistent with sepsis from pneumonia, although organism not identified. Transitioned to PO cefpodoxime on day 4.
Discharge meds: cefpodoxime 200 mg BID x3 more days; resume lisinopril, metformin, atorvastatin, omeprazole.
Follow-up: PCP in 1 week; repeat CXR in 6-8 weeks.
Condition: stable, home with husband.