Community-Acquired Pneumonia

A 66-year-old man with underlying chronic obstructive pulmonary disease (COPD) presents to the emergency department with a 2-day history of fever, dyspnea, and cough productive of green, purulent sputum. He had noted increasing dyspnea 3 days before the onset of fever. He describes one episode of acute exacerbation of COPD that occurred 6 months earlier. The physical examination is notable for mild respiratory distress and confusion, with disorientation to time. His temperature is 38.6 degrees C, heart rate 100 beats per minute, blood pressure 140/85 mm Hg, respiratory rate 24 breaths per minute, and oxygen saturation 92% while he is breathing ambient air. Auscultation of the lungs reveals coarse rhonchi over the right midlung field. Chest radiography reveals right upper-lobe consolidation (Fig. 1). His white-cell count is 14,000 per cubic millimeter, platelet count 159,000 per cubic millimeter, serum sodium 136 mmol per liter, blood urea nitrogen 19 mg per deciliter (6.8 mmol per liter), creatinine 1.1 mg per deciliter (97.2 mu mol per liter), and procalcitonin 5.4 ng per milliliter (normal range, 0.00 to 0.05). A multiplex viral panel was positive for respiratory syncytial virus. How would you further evaluate and treat this patient?

Automated summary

A 66-year-old man with underlying chronic obstructive pulmonary disease presents with fever, dyspnea, and productive cough. Physical examination reveals respiratory distress, confusion, and coarse rhonchi over the right midlung field. Chest radiography shows right upper-lobe consolidation. Laboratory findings include elevated white-cell count and procalcitonin, and a positive viral panel for respiratory syncytial virus.