Diagnose It Answer — April 7, 2026

58-year-old female presents with a 5-day history of productive cough with yellow-green sputum, fever, chills, and worsening shortness of breath. She states she felt like she had 'the flu' at first but has gotten progressively worse. She is now dyspneic at rest and having trouble completing sentences.

History of type 2 diabetes and moderate persistent asthma. Works as a school nurse. She received her influenza vaccine this year but has not had a pneumococcal vaccine. She denies recent travel or sick contacts beyond her students. Smoked for 10 years but quit at age 40. Takes metformin, albuterol PRN, and an inhaled corticosteroid.

BP 126/78 mmHg, HR 108 bpm, RR 28 breaths/min, Temp 39.4°C (103.0°F), SpO2 88% on room air — improved to 95% on 4L nasal cannula. Visibly short of breath, using accessory muscles. Skin warm and flushed. Confusion assessed: oriented to person and place only.

Lung auscultation reveals decreased breath sounds and coarse crackles in the right lower lobe with dullness to percussion at the right base. No wheezing. Trachea midline. PSI/PORT score calculated at class IV, indicating high-risk community-acquired infection requiring inpatient admission. Sputum specimen obtained for culture and Gram stain.

WBC 18,600/µL with left shift (12% bands). CRP 148 mg/L. Procalcitonin 3.4 ng/mL. Blood cultures x2 drawn. BMP: glucose 234 mg/dL, Na 131 mEq/L. Chest X-ray: right lower lobe consolidation with air bronchograms — classic lobar infiltrate. Urine Streptococcus pneumoniae antigen: positive. Legionella urinary antigen: negative.