MDM - Pneumonia (Discharge)

[##]-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].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation with noted [improvement/resolution] after treatment with [IV fluids/anti-pyretics/antibiotics].  Doubt sepsis or significant systemic infection at this time.  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 reported good social support, and access to follow up medical care.  Patient felt to be appropriate for outpatient treatment based on [overall stable appearance, response to treatment, and low 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].

Prior to discharge, we discussed return precautions, specifically for evidence of persistent or worsening infection, treatment with appropriate antibiotics [0bronchodilators/anti-pyretics], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

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)