Pneumonia
Pneumonia, DC
-Vitals notable for [borderline hypoxia] on arrival
-Overall sick but nontoxic. Presented with shortness of breath and cough. Coarse breath sounds present on the [R/L]. Initial chest XRay concerning for pneumonia. No respiratory distress. Labs were overall unremarkable. No high risk comorbidities or features. CURB-65 and PSI low risk. Patient states they feel better after meds. Other etiologies for dyspnea such as PE, ACS, CHF, Dissection, Asthma, COPD were considered but based on exam and findings above, I think it is most likely due to uncomplicated pneumonia. Antibiotics started here. Stable on RA. Discussed findings at length with patient. Also discussed that there is always a possibility that they may get worse regardless of our treatment decisions. They understood and stated they would like to go home with outpatient treatment and prompt PCP followup within the next 48 hours. Return precautions were extensively discussed and they understand to return for any worsening symptoms or failure to improve.
Pneumonia, Admit
-Vitals notable for [tachypnea, borderline hypoxia]
-Overall ill-appearing. Presented with shortness of breath and cough. Coarse breath sounds present on the [R/L]. CXR concerning for pneumonia. Comorbidities and high risk features include []. Given their presentation, history, and exam I think they will benefit from IV antibiotics and inpatient admission. Drawing cultures as well. Overall [does/doesn’t] seem septic. Currently stable on nasal cannula. At this point I think more malignant etiologies such as PE, ACS, CHF are all possibilities although it seems more likely to be isolated pneumonia. Discussed admission with hospitalist and they agree with the plan. The plan was also discussed with the patient.
- Last updated January 27, 2023