Pneumonia in a patient with COPD

EXAM: XR chest PA and lateral. FINDINGS: Dense consolidation left lower lobe with air bronchograms. Hyperinflated lungs with flattened hemidiaphragms, consistent with emphysematous change. No effusion. Normal heart size. IMPRESSION: 1. Left lower lobe pneumonia. 2. Chronic emphysematous changes.

CC: cough, fever, SOB. HPI: 69 y/o M with COPD (no home O2), HTN, HLD, GERD, current smoker 1 ppd, presents with 3 days productive cough with green sputum, fevers to 38.6, pleuritic L-sided chest pain, and increased SOB. Using albuterol 2-3x/day (usual 1x/day). No sick contacts. Vitals: T 38.4, HR 104, RR 22, BP 142/84, SpO2 90% RA -> 94% on 2 L NC. Exam: Mild increased WOB, speaking full sentences. Bronchial breath sounds and crackles L base. Scattered end-expiratory wheeze (pt states "always a little wheezy"). No edema. Labs: WBC 15.4 (88% PMN). Na 136, K 4.2, Cr 1.0, BUN 17. Procalcitonin 1.8. Lactate 1.6. VBG pH 7.39 / pCO2 46. CXR: LLL consolidation. ED course: Duoneb x1, ceftriaxone 1 g + azithromycin 500 mg IV. R/o COPD exacerbation. Impression: LLL pneumonia in COPD patient. Admit to hospitalist.

HISTORY AND PHYSICAL HPI: 69M, COPD GOLD 3 (FEV1 44% predicted, 2025), active smoker 45 pack-years, presents with 3 days productive cough, fever, pleuritic pain, LLL consolidation on CXR, WBC 15.4, PCT 1.8. PMH: COPD on tiotropium/olodaterol, HTN, HLD, GERD. Meds: tiotropium/olodaterol 2 puffs daily, albuterol PRN, amlodipine 5 mg, simvastatin 20 mg, pantoprazole 40 mg. SH: smokes 1 ppd, interested in quitting. No EtOH. Exam: T 38.1, HR 98, RR 20, SpO2 93% 2 L. LLL crackles, bronchial BS. Mild baseline expiratory wheeze, good air movement, no accessory muscle use. ASSESSMENT/PLAN: 1. Community-acquired pneumonia, LLL, bacterial - ceftriaxone 1 g daily + azithromycin x 3 days. Sputum cx, strep/legionella urine Ag. O2 to SpO2 88-92%. 2. COPD with acute lower respiratory infection (the LLL pneumonia). I do not think this is a COPD exacerbation: wheeze at baseline per pt, good air movement, VBG with normal pH. Continue home tiotropium/olodaterol, albuterol PRN. No systemic steroids. 3. Tobacco use disorder, cigarettes - nicotine patch 21 mg, cessation counseling. 4. HTN - continue amlodipine. 5. HLD - continue simvastatin. 6. GERD - continue pantoprazole. DVT ppx enoxaparin. Full code.

S: Less SOB, pleuritic pain improved, cough productive. Slept OK. O: Tmax 37.6, HR 86, RR 18, SpO2 92% on 1 L, 90% RA at rest. Lungs: LLL crackles, minimal wheeze. WBC 11.0. Strep pneumo and legionella urine Ag negative. Sputum cx: normal respiratory flora. A/P: 1. LLL community-acquired pneumonia, organism not identified - continue ceftriaxone, d/c azithro after dose 3. Wean O2. 2. COPD with acute lower respiratory infection - stable, no exacerbation, no steroids needed. 3. Tobacco use disorder - patch, counseling done. 4. HTN, HLD, GERD - home meds.

Pt resting, no acute distress. Weaned to RA at 22:00 per protocol, SpO2 90-92% at rest, 89-90% ambulating to BR, recovered quickly with pursed-lip breathing. Productive cough, small amt yellow sputum. Lungs diminished L base. Using home inhaler as scheduled, albuterol x1 overnight. Nicotine patch in place, pt asked for cessation pamphlet, provided. Afebrile. Voiding qs. Ambulating independently.

DISCHARGE SUMMARY Admit 09/15/2026 - Discharge 09/18/2026. Home. Principal diagnosis: Community-acquired pneumonia, left lower lobe. Secondary diagnoses: COPD with acute lower respiratory infection (no exacerbation). Nicotine dependence, cigarettes. Hypertension. Hyperlipidemia. GERD. Hospital course: Treated with ceftriaxone/azithromycin with clinical improvement; weaned to room air HD3 (SpO2 92% RA at rest and 90% with ambulation, no home O2 needed). Urine antigens negative and sputum culture with normal flora; no organism identified. COPD remained at baseline throughout without steroids. Discharge meds: amoxicillin-clavulanate 875 mg BID x 3 days; home inhalers; nicotine patch 21 mg daily; amlodipine, simvastatin, pantoprazole. Follow-up: PCP 1 week; pulmonary clinic 6 weeks; repeat CXR 6-8 weeks; smoking cessation program referral placed.