CC: SOB, cough, fever.
HPI: 68M with HTN, HLD, BPH, R knee OA, former smoker (35 pk-yr, quit 2014) presents with 4 days of cough with yellow sputum, fevers, and worsening SOB since last night; now dyspneic speaking in short phrases.
ROS: + fever, chills, cough, dyspnea. Denies CP, hemoptysis, leg swelling, recent travel.
Vitals: T 38.8C, HR 108, RR 30, BP 138/82, SpO2 84% RA.
Exam: Tachypneic, using accessory muscles (SCM retractions). Crackles L base with egophony. RRR. No edema.
Labs: WBC 15.9, Hgb 14.2, Plt 288. BMP: Na 137, K 3.9, Cr 1.0, glucose 128. Lactate 1.6. Procalcitonin 1.8. Flu/COVID/RSV PCR negative.
CXR (my read): LLL consolidation.
MDM: CAP, LLL. Hypoxic on RA, placed on 4L NC with SpO2 90%. Ceftriaxone + azithromycin. Admit to medicine, step-down level.
EXAM: XR chest portable AP.
FINDINGS: Lobar consolidation left lower lobe with air bronchograms. No pleural effusion or pneumothorax. Right lung clear. Cardiomediastinal silhouette normal. Emphysematous changes not well evaluated on portable technique.
IMPRESSION: Left lower lobe pneumonia.
HPI: As per ED. 68M with 4d productive cough and fever, now with SOB. SpO2 84% RA in ED, 90% on 4L NC.
PMH: HTN, HLD, BPH, OA R knee. Former smoker, quit 2014.
Meds: amlodipine 10 mg, atorvastatin 40 mg, tamsulosin 0.4 mg qHS, acetaminophen PRN knee pain.
Exam: T 38.5, HR 104, RR 26, BP 134/80, SpO2 91% 4L NC. Crackles LLL.
Assessment/Plan:
1. LLL community-acquired pneumonia - ceftriaxone 1 g daily + azithromycin 500 mg daily. Sputum/blood cx. Legionella/pneumococcal Ag.
2. Hypoxia - on 4L NC, titrate to SpO2 > 90%, wean as tolerated.
3. HTN - continue amlodipine.
4. HLD - continue atorvastatin.
5. BPH - continue tamsulosin; no LUTS currently.
6. OA R knee - acetaminophen PRN.
DVT ppx: enoxaparin. Code: Full.
Reason for consult: worsening oxygenation.
HPI: 68M admitted this AM with LLL CAP. Rapid response called 15:30 for SpO2 86% on 4L NC, RR 32, increased work of breathing.
Exam: Anxious, speaking 3-4 word sentences, accessory muscle use with intercostal retractions. RR 30. Bronchial breath sounds LLL. No wheeze. No stridor.
ABG on 4L NC: pH 7.46 / pCO2 33 / pO2 54 / HCO3 23. P/F approx 150.
Bedside US: A-lines R, consolidation with dynamic air bronchograms LLL, no effusion.
Assessment:
1. Acute hypoxic respiratory failure secondary to LLL community-acquired pneumonia. SpO2 84% RA on presentation, RR 30, accessory muscle use, pO2 54 on 4L NC.
2. LLL CAP - agree with current antibiotics.
3. Remote tobacco use; no prior PFTs. No clinical evidence of obstructive lung disease on exam; will not label COPD without spirometry.
Recommendations:
- Escalate to high-flow nasal cannula 40 L/min, FiO2 50%, goal SpO2 92-96%.
- Continue ceftriaxone/azithro.
- Low threshold for ICU transfer / BiPAP if worsening; not currently requiring intubation.
- Outpatient PFTs after recovery.
S: Overnight on HFNC, work of breathing improved. Still coughing.
O: T 37.9, HR 94, RR 22, BP 128/76. SpO2 94% on HFNC 30 L/40%. Crackles LLL. WBC 13.2. Blood cx NGTD. Urine Ag negative.
A/P:
1. Acute hypoxic respiratory failure due to LLL pneumonia - agree with pulmonology. Improving; weaning HFNC, goal transition to NC today.
2. LLL CAP - continue ceftriaxone/azithro.
3. HTN, HLD, BPH, OA - home meds.
Admit: 09/10/2026 Discharge: 09/14/2026
Discharge diagnoses:
1. Left lower lobe community-acquired pneumonia, organism not identified
2. Acute hypoxic respiratory failure secondary to #1, resolved
3. Hypertension
4. Hyperlipidemia
5. BPH
6. Osteoarthritis, right knee
Hospital course: Presented with fever, productive cough and SpO2 84% RA. Required escalation to HFNC (max 40 L/50%) on day 1 per pulmonology for acute hypoxic respiratory failure; weaned to 2L NC on day 2 and to room air on day 3 (SpO2 94% RA at rest and ambulation). Treated with ceftriaxone/azithromycin, transitioned to PO amoxicillin-clavulanate. Cultures negative.
Discharge meds: amoxicillin-clavulanate 875 mg BID x4 days; home amlodipine, atorvastatin, tamsulosin.
Follow-up: PCP 1 week; pulmonology with PFTs and repeat CXR in 6-8 weeks.