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)

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)

Decision Rule - CURB-65 Score

CURB-65 Score for Pneumonia:

-Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-BUN >19 mg/dL (>7 mmol/L) . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-Respiratory rate >30 bpm . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-Systolic BP <90 mmHg or diastolic BP ≤60 mmHg  . .  [No (+0 points)/Yes (+1 point)]

-Age ≥65  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

TOTAL = [## points]

Patient is determined to be low risk (0-1 points) with a 1.5% mortality, and recommendation for close outpatient care.

Patient is determined to be moderate risk (2 points) with a mortality of 9.2%, and recommendation for inpatient versus observation admission.

Patient is determined to be high risk (≥3 points) with a mortality of 22% and inpatient treatment and consideration of ICU admission is recommended for a score of 4-5.

https://www.mdcalc.com/curb-65-score-pneumonia-severity

Discharge Instructions - Pneumonia

As discussed in the Emergency Department prior to discharge, you have been diagnosed with pneumonia.  Pneumonia is a lung infection that can cause coughing, fever, and trouble breathing.  The lung infection is often caused by bacteria, but it can also be caused by viruses or other microorganisms.

Doctors use the term "community-acquired" when a person catches an infection in their daily life, and not from being in the hospital.  Doctors call it "hospital-acquired" when people catch an infection from being in the hospital.

Community-acquired pneumonia can be mild or severe.  A mild infection is sometimes called "walking pneumonia."  That's because most people with walking pneumonia are not very sick and can still walk around and do their daily activities.

Common symptoms of pneumonia include cough, coughing up mucus (sputum), fever, chest pain (especially when taking a deep breath), a fast heartbeat, and shaking chills.

Doctors treat community-acquired pneumonia with antibiotic medicines.  These medicines kill the germs that are causing the infection.  Most people can take antibiotic pills at home, but some people need to be treated in the hospital.  People who are treated in the hospital usually get antibiotics through a thin tube that goes into their vein, called an "IV."  Some people also get extra oxygen to help them breathe more easily.

Most people start to feel better within 3 to 5 days of taking their medicine.  But a cough from pneumonia can last weeks or months after treatment.  If your symptoms do not improve or get worse after starting treatment, tell your doctor or nurse.

You should also be sure to get plenty of rest, drink plenty of fluids, and take a fever-reducing medicine, if you have a fever.

Return to the Emergency Department for worsening chest pain, significant difficulty breathing, fever (≥38.0 °C or 100.4 °F) after 2 days of antibiotics, significant fast heartbeat, inability to tolerate fluids or antibiotics by mouth, confusion, or any new or concerning symptoms.

MDM - Sepsis

[##]-year-old [male/female] with [altered mental status/fever/weakness/etc.] with history and exam consistent with sepsis from [unclear infectious source/pneumonia/urinary tract infection (UTI)/etc.].

Patient felt to have symptoms concerning for a potential infection based on [fever (temperature ≥100.4°F)/elevated heart rate (>90)/elevated respiratory rate (>20 or PaCO₂ < 32 mmHg)] noted at time of initial triage.  Labs were obtained to include a lactate level, CBC, and blood cultures, and were notable for [leukocytosis (>12,000/mm³)/leukopenia (<4,000/mm³)/bandemia (>10% bands)] concerning for systemic inflammatory response (SIRS).  The patient was noted to have an initial lactate that was [within normal limits/minimally/moderately/significantly elevated]. 

We considered possible respiratory sources for infection and obtained a chest x-ray [and additional imaging], which was [notable for pneumonia/unremarkable].  We considered possible urinary sources of infection and obtained a urinalysis and urine culture, which was [notable for findings suggestive of a UTI/unremarkable].  We considered possible soft tissue sources for infection [and noted findings on the LOCATION consistent with cellulitis/abscess/fasciitis].  We considered [additional infectious sources] and obtained [additional testing] which was [notable for FINDING/noted to be unremarkable].

Based on findings SIRS criteria and [presumed infectious source], the patient was felt to meet criteria for sepsis.  Broad spectrum antibiotic coverage was initiated within 3 hours of ED triage with [antibiotics used].  Resuscitation with crystalloids IV [was initiated as a 30 mL/kg bolus/was initiated as ### mL boluses due to patient’s history of heart failure/etc.].  Vasopressors [were/were not] felt to be indicated due to [ability/inability] to maintain mean arterial pressure (MAP) of ≥65 mmHg [after/despite] crystalloid boluses.  The patient was felt to have [no] evidence of septic shock based on [no/vasopressor requirement to maintain MAP ≥65 mmHg and/or serum lactate >2 mmol/L despite resuscitation with crystalloids/without evidence of hypovolemia].

Patient noted to have a qSOFA score of [##] suggestive of [<1 patient who is not high risk for poor outcome/≥2 high risk of poor outcome], so the patient was felt to meet criteria for admission to [general floor with telemetry/step down unit/ICU].  We discussed presumed diagnosis of [unknown/infectious source] with findings concerning for sepsis with the [patient/family/caregiver].  We discussed plan for admission for further treatment, and the [patient/family/caregiver] demonstrated understanding and agreement with this plan.

We discussed the case with Dr. [Name] who agreed with need for admission to the [general floor with telemetry/step down unit/ICU] for further treatment of [infection and sepsis].

https://www.mdcalc.com/sirs-sepsis-septic-shock-criteria

https://www.mdcalc.com/qsofa-quick-sofa-score-sepsis