MDM - Pneumonia (Admit)

[##]-year-old [male/female] with history and exam consistent with [viral/atypical/community-acquired] pneumonia.

Initial consideration in this patient included pneumonia, bronchitis, influenza, upper respiratory infections (URI), malignancy, atelectasis, tuberculosis, pulmonary embolism (PE), diffuse alveolar hemorrhage, and cardiac etiologies among others. 

Patient presented with [fever, productive cough, abnormal lung sounds] concerning for pneumonia.  A chest x-ray was obtained in the evaluation of this patient and was notable for [right/left/upper/middle/bilateral/multifocal consolidation(s) with/without associated effusion].  Labs were obtained and were notable for [leukocytosis with a leftward shift/etc.].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation [with/without significant improvement] after treatment with [IV fluids/anti-pyretics/antibiotics].  Patient felt to [not] have evidence of [sepsis/septic shock] based on [relevant abnormalities].  Blood cultures were obtained due to planned admission for pneumonia. 

Patient felt to be low risk for PE based on history, exam, and absence of significant risk factors.  No significant risk factors to suggest cardiac etiology for symptoms.

Patient noted to have [no] recent antibiotic use.  Patient noted to have [no] recent admission to a hospital or residence in a nursing home.  Hospital-acquired pneumonia felt to be [likely/unlikely] in this patient.

Patient felt to not be appropriate for outpatient treatment of pneumonia based on [evidence of sepsis, absence of good social support and moderate/high risk CURB-65 score as noted above].  Antibiotics were selected based on [facility antibiogram/professional guidelines/to cover for community-acquired/healthcare-associated and atypical pathogens] and initiated in the ED.

We discussed planned admission with the patient who demonstrates understanding and agreement with this plan.  We discussed case with Dr. [NAME] who evaluated the patient and agrees with need for admission to [general floor/telemetry unit/step-down unit/ICU].

https://www.mdcalc.com/curb-65-score-pneumonia-severity
https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap

https://wikem.org/wiki/Pneumonia_(main)