Patient
71-year-old male, hospital discharge
Admitting Information
Admission Date: June 7, 2026
Discharge Date: June 12, 2026 (5 days)
Attending Physician: Dr. James Park, Hospitalist Service
Primary Care Provider: Dr. Lisa Wong, Internal Medicine Associates
Reason for Admission: Community-acquired pneumonia with sepsis
History of Present Illness
Patient presented to ED with 5-day history of productive cough (yellow-green sputum), fevers to 103 F, rigors, right-sided pleuritic chest pain, and progressive shortness of breath. Symptoms began after upper respiratory infection in household contact (grandchild). Did not improve with azithromycin Z-pack started by PCP 3 days prior to presentation. Developed confusion on day of presentation, prompting family to bring to ED.
Past Medical History
COPD (GOLD Stage II, FEV1 68% predicted) — on tiotropium + fluticasone/salmeterol
Atrial fibrillation (paroxysmal) — on apixaban, rate-controlled
Hypertension
Benign prostatic hyperplasia
Type 2 Diabetes Mellitus (on metformin)
Prior: tobacco use 40 pack-years, quit 2008
Hospital Course
Day 1 (Admission): Admitted to general medicine floor for CAP + sepsis (qSOFA 2: altered mental status, RR 22). Started on ceftriaxone 1 g IV daily + azithromycin 500 mg IV daily. Chest X-ray: right lower lobe consolidation consistent with pneumonia. Blood cultures x2 sent. Lactate 3.2. Started 2L NC O2 for SpO2 89% on RA.
Day 2: Fevers persisted to 101.2 F. Mental status improved — back to baseline. Oxygen weaned to room air (SpO2 94%). Lactate normalized to 1.4. Procalcitonin trended down (4.2 -> 2.1 ng/mL).
Day 3: Blood cultures returned positive — Streptococcus pneumoniae, pansensitive. Defervesced, afebrile for 24h. Cough improving, sputum production decreased. ID consulted: azithromycin stopped; continue beta-lactam alone. Planned total course 10 days given bacteremia.
Day 4: Remained afebrile. Repeat CXR showed partial resolution of RLL infiltrate. Ambulating independently. Tolerating regular diet.
Day 5 (Discharge Day): Clinically stable. Afebrile for 48+ hours. SpO2 95% RA. Cleared for discharge to complete the course with oral amoxicillin.
Discharge Diagnoses
Primary: Sepsis due to Streptococcus pneumoniae (A40.3) with pneumococcal pneumonia (J13)
Secondary: Severe sepsis without septic shock (R65.20)
Acute respiratory failure with hypoxia (J96.01)
Septic encephalopathy (G93.41)
COPD with acute lower respiratory infection (J44.0)
Discharge Medications
Amoxicillin 1 g PO TID x 5 days — NEW (completes 10-day total course)
Tiotropium 18 mcg inhalation once daily — RESUME HOME REGIMEN
Fluticasone/salmeterol 250/50 mcg 1 puff BID — RESUME HOME REGIMEN
Apixaban 5 mg PO BID — CONTINUE
Lisinopril 10 mg daily — RESUME
Tamsulosin 0.4 mg nightly — RESUME
Metformin 500 mg PO BID — RESUME (held during acute illness)
Acetaminophen 500-1000 mg q6h PRN pain/fever — NEW, as needed
Albuterol HFA 2 puffs q4-6h PRN wheezing — RESUME HOME REGIMEN
Medication Reconciliation: Verified all home medications. Pharmacy reviewed for interactions. No discrepancies.
Discharge Instructions
Activity: Gradually increase activity as tolerated. Avoid strenuous exercise for 1 week. May walk short distances.
Diet: Regular diet. Ensure adequate hydration (aim for 2-3 liters/day while on antibiotics).
Wound Care: N/A
Oxygen: Discontinued. Home O2 not required. If SpO2 <90% at home, return to ED.
Warning Signs — RETURN TO ED or CALL 911 for:
- Fever > 101.5 F after 48 hours of antibiotics
- Increasing shortness of breath or inability to speak in full sentences
- Confusion or altered mental status
- Chest pain
- Inability to tolerate oral medications or fluids
- New or worsening cough with bloody or dark sputum
Follow-up Appointments
- Primary Care (Dr. Lisa Wong): Schedule within 7-10 days of discharge. Office already contacted; appointment pending confirmation.
- Pulmonology (Dr. Anita Sharma): Follow-up in 6-8 weeks with chest X-ray (age and 40 pack-year history) and COPD review. Appointment scheduled for July 31, 2026.
- Lab work: CBC with differential in 1 week at outside lab (requisition provided). Call PCP office with results.
Condition at Discharge: Improved. Afebrile for 48+ hours. Respiratory status stable on room air. Ambulating independently. Mentally back to baseline.