A 54-year-old smoker with multiple comorbidities (diabetes, hypertension, coronary artery disease) presents with a 2-day history of a productive cough with yellow sputum, chest tightness, and fever. Physical exam reveals a temperature of 101°F (38.3°C), BP of 150/95 mmHg, heart rate of 85 bpm, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 95% at rest; lung sounds are distant but clear, with crackles at the left base. Chest x-ray reveals a left lower lobe infiltrate.
Pneumonia can occur at any age, but the incidence increases significantly in old age, and pneumonia is a leading cause of illness and death in older patients. The clinical manifestations of pneumonia in elderly persons are often less intense than those in younger patients. Atypical pathogens such as Mycoplasma pneumoniae, Chlamydophila pneumophila, and respiratory viruses can present in a subacute fashion with gradual onset of fever, nonproductive cough, constitutional symptoms, relatively normal white blood cell count, and absent or diffuse findings on lung exam. Patients with severe pneumococcal or Legionella pneumophila pneumonia often progress rapidly to respiratory failure.
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