Discharge Summary Template

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

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.

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 (diet-controlled)

Prior: tobacco use 40 pack-years, quit 2008

Day 1 (Admission): Admitted to general medicine floor for CAP + sepsis (qSOFA 2: altered mental status, RR 22). Started on ceftriaxone 2g IV q12h + azithromycin 500mg IV daily per ID recommendation. 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: recommended de-escalation to ceftriaxone monotherapy given sensitivity profile. Total planned course: minimum 5 days IV from first afebrile day.

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 on oral antibiotic completion.

Primary: Community-acquired pneumonia due to Streptococcus pneumoniae, severe, with sepsis (ICD-10: A41.3, J15.5)

Secondary: Acute hypoxic respiratory failure (J96.0)

Acute encephalopathy secondary to sepsis (G93.41)

COPD exacerbation (J44.1)

Amoxicillin-clavulanate 875/125 mg PO BID x 7 days (complete 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 — RESUME (held during acute illness, resumed day 3)

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.

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

Condition at Discharge: Improved. Afebrile for 48+ hours. Respiratory status stable on room air. Ambulating independently. Mentally back to baseline.