Hospital Course

The patient is a 68-year-old male who presented with acute onset SOB, productive cough, and fever for 3 days. Our evaluation showed leukocytosis (WBC 16,200 /mm³), CRP 112 mg/L, and CXR demonstrating a RLL consolidation; he was administered ceftriaxone 1 g IV and azithromycin 500 mg IV in the ED. Based on these findings, the presentation was most consistent with community-acquired pneumonia (CAP), although the differential diagnosis included acute pulmonary embolism (PE), acute decompensated heart failure (ADHF), and acute exacerbation of COPD. PE was considered less likely given the presence of fever, purulent sputum, and lobar consolidation without tachycardia or unilateral leg swelling. ADHF was excluded due to the absence of JVD, peripheral edema, or cardiomegaly on CXR, alongside a normal BNP (45 pg/mL). Acute COPD exacerbation was ruled out as the primary driver given no prior history of chronic bronchitis or emphysema and focal parenchymal infiltrate on imaging. The patient was admitted with community-acquired pneumonia for IV antibiotic therapy and supplemental oxygen.

On admission (12/05/2026), the patient required 2 L/min O2 via nasal cannula to maintain SpO2 > 92 %. He was continued on ceftriaxone 1 g IV Q24H and azithromycin 500 mg IV Q24H. Sputum and blood cultures drawn prior to antibiotic initiation remained negative at 48 hours. By hospital day 2 (13/05/2026), his fever resolved, leukocytosis improved to 11,400 /mm³, and he was successfully weaned off supplemental oxygen, maintaining an SpO2 of 96 % on room air during ambulation. Having achieved clinical stability, he was transitioned to oral amoxicillin/clavulanate (Augmentin®) and doxycycline on 14/05/2026 and cleared for discharge home.

Physical Exam

• Constitutional: Alert, oriented x3, NAD.
• Vital Signs: T 36.8 °C, HR 76 bpm, BP 128/78 mmHg, RR 16 /min, SpO2 96 % on room air.
• Eyes: Conjunctivae clear, anicteric sclerae, PERRLA.
• Ears, Nose, Throat: Oropharynx clear, mucous membranes moist, no pharyngeal erythema.
• Neck: Supple, no JVD, no cervical lymphadenopathy.
• Cardiovascular: RRR, normal S1/S2, no murmurs, rubs, or gallops, peripheral pulses 2+ bilaterally.
• Respiratory: Normal respiratory effort, decreased breath sounds and faint inspiratory crackles at the right lung base, left lung clear to auscultation, no wheezes or rhonchi.
• Gastrointestinal: Soft, non-tender, non-distended, normoactive bowel sounds.
• Musculoskeletal: Normal gait and station.
  • Right knee: No effusion, full ROM, negative McMurray test, negative anterior and posterior drawer signs.
• Skin: Warm, dry, intact, no rashes or cyanosis.
• Neurologic: CN II-XII intact, motor strength 5/5 throughout, sensation intact to light touch.
• Psychiatric: Cooperative, appropriate mood and affect.

Assessment & Plan

The patient is a 68-year-old male who presented with acute onset SOB, productive cough, and fever for 3 days. Our evaluation showed leukocytosis (WBC 16,200 /mm³), CRP 112 mg/L, and CXR demonstrating a RLL consolidation; he was administered ceftriaxone 1 g IV and azithromycin 500 mg IV in the ED. Based on these findings, the presentation was most consistent with community-acquired pneumonia (CAP), although the differential diagnosis included acute pulmonary embolism (PE), acute decompensated heart failure (ADHF), and acute exacerbation of COPD. PE was considered less likely given the presence of fever, purulent sputum, and lobar consolidation without tachycardia or unilateral leg swelling. ADHF was excluded due to the absence of JVD, peripheral edema, or cardiomegaly on CXR, alongside a normal BNP (45 pg/mL). Acute COPD exacerbation was ruled out as the primary driver given no prior history of chronic bronchitis or emphysema and focal parenchymal infiltrate on imaging. The patient was admitted with community-acquired pneumonia for IV antibiotic therapy and supplemental oxygen.

Community-acquired pneumonia J18.9

Assessment: Clinically improved, afebrile for > 24 hours, and normoxic on room air. Admission CXR (12/05/2026) showed RLL consolidation. WBC decreased from 16,200 /mm³ (12/05/2026) to 9,100 /mm³ (14/05/2026). Blood cultures from 12/05/2026 show no growth to date. Ready for discharge on oral step-down therapy.

Plan:

Medications:

• amoxicillin/clavulanate (Augmentin®) 875 mg/125 mg PO BID for 5 days
• doxycycline (Vibramycin®) 100 mg PO BID for 5 days
• paracetamol (acetaminophen, Tylenol®) 650 mg PO Q6H PRN fever or pain

Other Orders:

• Incentive spirometry 10 breaths every hour while awake.
• Smoking cessation counseling provided.
• Repeat CXR in 6 weeks to confirm resolution of RLL infiltrate.

Follow Up: Follow up with PCP, Dr. Sarah Jenkins (Family Medicine), in 7 days.

Essential hypertension I10

Assessment: Stable and well-controlled during admission. BPs ranged from 122/74 mmHg to 134/82 mmHg. BMP on 14/05/2026 showed Cr 0.9 mg/dL and K 4.1 mmol/L. Home antihypertensive regimen was held on admission day due to acute illness and resumed on 13/05/2026 without issue.

Plan:

Medications:

• lisinopril (Prinivil®, Zestril®) 20 mg PO daily, indefinitely

Other Orders:

• Continue home BP monitoring daily.
• Maintain low-sodium diet (< 2 g/day).

Follow Up: Routine management with PCP in 7 days.