CC: cough, fatigue x 4 days.
HPI: 71 y/o M with HTN, HLD, T2DM (metformin), GERD presents with productive cough (yellow sputum), subjective fevers, mild fatigue x 4 days. Mild SOB on exertion only. No chest pain, no confusion, eating and drinking OK. Wife states he "just isn't himself." No recent hospitalization or antibiotics.
ROS: + cough, + subjective fever, + fatigue. Neg for CP, syncope, dysuria, N/V/D, rash.
Vitals: T 37.9 C, HR 96, RR 18, BP 132/78 (MAP 96), SpO2 95% RA.
Exam: Alert, oriented x3, NAD. Mucous membranes moist. Crackles R base, no wheeze. RRR, no murmur. Abd soft, NT. No edema. Cap refill < 2 sec.
Labs: WBC 11.2, Hgb 13.9, Plt 231. Na 138, K 4.1, Cr 0.9 (baseline 0.9), BUN 16, glucose 168. Lactate 1.1. Procalcitonin 0.22. Bili 0.6.
CXR: RLL opacity (see radiology).
ED course: 1 L LR given per triage protocol, ceftriaxone 1 g IV + azithromycin 500 mg IV. BP remained 128-136 systolic throughout.
Impression: RLL community-acquired pneumonia. Patient asks to go home but family uncomfortable; will admit to hospitalist for IV abx and observation of response.
EXAM: XR chest PA/lateral.
INDICATION: cough, fever.
FINDINGS: Patchy airspace opacity in the right lower lobe. No pleural effusion. No pneumothorax. Heart size normal. Mild degenerative changes thoracic spine.
IMPRESSION: Right lower lobe airspace opacity compatible with pneumonia in the appropriate clinical setting.
HISTORY AND PHYSICAL
CC: cough, fever.
HPI: 71M with HTN, HLD, T2DM, GERD here with 4 days productive cough, subjective fevers, fatigue. Seen in ED, CXR with RLL opacity. Given ceftriaxone/azithro and 1 L LR.
PMH: HTN, HLD, T2DM (last A1c 7.2%), GERD.
Meds: lisinopril 20 mg daily, atorvastatin 40 mg nightly, metformin 1000 mg BID, omeprazole 20 mg daily.
SH: Retired machinist. Never smoker. Rare EtOH.
Vitals: T 37.8, HR 94, RR 18, BP 130/76, SpO2 95% RA.
Exam: Pleasant, conversant, A&Ox3. Crackles RLL. Heart RRR. Abd benign. No edema.
Labs: WBC 11.2, lactate 1.1, Cr 0.9, Plt 231, bili 0.6.
ASSESSMENT/PLAN:
1. Sepsis due to RLL community-acquired pneumonia - meets SIRS (HR > 90, WBC > 11). Continue ceftriaxone 1 g IV daily + azithromycin x 3 days. Blood cx x2, sputum cx. Trend vitals. Maintenance IVF only, encourage PO.
2. HTN - continue lisinopril.
3. HLD - continue atorvastatin.
4. T2DM - hold metformin while inpatient, SSI, carb-consistent diet.
5. GERD - continue PPI.
DVT ppx: enoxaparin. Code: Full. Dispo: anticipate 24-48 h.
HD2 AM labs: WBC 9.4, Hgb 13.5, Plt 226. Na 139, K 4.0, Cr 0.8, BUN 13, glucose 142.
Lactate (repeat): 0.9.
Blood cultures x2 (09/03): no growth at 24 h.
Sputum culture: normal oropharyngeal flora.
Vitals trend (flowsheet): Tmax 37.9 C (09/03 10:10), last 36.9 C; HR 78-96; RR 16-18; SBP 124-138, no MAP < 65 recorded; SpO2 94-97% RA throughout. No vasopressors. GCS 15 throughout.
S: Feels better. Cough improving, ate full breakfast. No fevers overnight.
O: T 36.9, HR 80, RR 16, BP 128/74, SpO2 96% RA. Lungs: faint RLL crackles. Labs: WBC 9.4, lactate 0.9, Cr 0.8. BCx NGTD.
A/P:
1. Sepsis due to RLL CAP - clinically improving. Transition to PO cefpodoxime + finish azithromycin. Likely d/c tomorrow if remains afebrile.
2. HTN - controlled. 3. HLD - statin. 4. T2DM - BG 140s on SSI; resume metformin at d/c. 5. GERD - PPI.
DISCHARGE SUMMARY
Admit: 09/03/2026. Discharge: 09/05/2026. Dispo: home with wife.
Principal diagnosis: Sepsis due to right lower lobe community-acquired pneumonia.
Secondary diagnoses: Hypertension. Hyperlipidemia. Type 2 diabetes mellitus without complications. GERD.
Hospital course: 71M admitted with productive cough and low-grade temp, RLL opacity on CXR. Treated with ceftriaxone/azithromycin, transitioned to PO cefpodoxime HD2. Remained hemodynamically stable on room air throughout. Lactate normal x2, renal function at baseline, blood cultures no growth. Afebrile > 24 h at discharge, eating well, ambulating independently.
Discharge meds: cefpodoxime 200 mg PO BID x 4 more days; resume home lisinopril, atorvastatin, metformin, omeprazole.
Follow-up: PCP in 1 week; repeat CXR in 6-8 weeks.