67 yr old man presents with 3 day history of worsening productive cough and

dyspnea. Patient reports yellow-green sputum associated with cough and as of today
there is blood in sputum. Patient also reports a fever of 101 that is not relieved
by Tylenol. Patient also reports pleuritic chest pain on left side.
ROS: no headaches, no visual or audio disturbances, no palpable lymph nodes, no
joint pain, no urinary problems
PMHx: COPD diagnosed 1 year ago
Meds: Albuterol and Spiriva inhalers as needed
Allergies: NKDA
FHx: parents deceased of natural causes
SHx: 40 pack year history of smoking

PE:
-General: older aged male, well kept and in no apparent distress. AAOx3
-Vitals: Temp 101.5 PP-100, BP 110/65
-HEENT: dry mucous membranes, no significant lymphadenopathy
-Chest: Coarse crackles and egophony at left lung base
-Cardio: tachycardic, no murmurs
-Lab testing shows elevated WBC level (12.5), slightly lowered RBC level (4.1),
elevated BUN level (32), Procalcitonin level of 10.6 ng/mL, increased C reactive
protein
-EKG testing normal
-Chest X-ray shows consolidation in posterior left lobe.

Assessment:
DDX1: Pneumonia----> Cough, Fever, consolidation on chest x-ray, yellow sputum
DDX2: CHF-----> dyspnea, smoking history, chest pain

Plan:
Admit patient to hospital. Sputum/ blood cultures. Begin antibiotic treatment with
ceftriaxone and azithromycin. Initiate CPAP. Cardiac stress test. DVT prophylaxis.
Obtain arterial blood gas.