A 34-year-old woman is admitted with a history of fever, chills, and greenish sputum for 10 days. She has history of ETOH and substance abuse. On physical examination, vital signs are: pulse 113 bpm; temperature 101degF; respirations 25/min; blood pressure 110/78 mm Hg. She looks ill and has crackles with egophony and E to A changes in the right upper lung field. Laboratory data: Hb 12 g/dL; Hct 37%; WBCs 15.0/uL; differential BUN 48 mg/dL; creatinine 1.7 mg/dL. Chest radiographs are shown below.What is the most likely diagnosis?

This x-ray shows a large lobar density in the right upper lobe with some area of incomplete consolidation in the density. The lower end of this opacity is bulging and the horizontal fissure is displaced downward. The chest x-ray and the clinical picture are consistent with pneumonia. The bulging fissure with a densely consolidated lobe has been described with klebsiella pneumonia, although it can occur more frequently with S. pneumomiae. Tuberculosis pneumonia would show cavitary disease with loss of volume. A loculated empyema presents as a pleural base opacity. Based on the diagnosis of pneumonia, the next management step is to sta the antibiotics. Because of the immune-compromised status of the patient as well as the extent of the pneumonia, complications would include ARDS and septic shock. Hyponatremia is seen with pneumonia and indicates inappropriate ADH secretion. Although patients with ETOH abuse may have pancreatitis per se, this is not a complication of pneumonia.