CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Similar sx before-
Fever- , Chills- , Sweating-
Persistent- , Intermittent-
Sick contacts- ,Travel- , Pets-
Immunizations-
PAST SURGICAL HISTORY (positives are circled):
CABG Cholecystectomy Hernia GSW Hysterectomy C-section
MEDICATIONS:
ALLERGY: NKDA
FMH (positives are circled):
CAD<> 55 yo DM Stroke HTN CA
SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol:
Smoker:
Illicit drugs:
REVIEW OF SYSTEMS: unremarkable apart from the symptoms above
PHYSICAL EXAM:
VITALS: Orthostatics-
SpO2- Initial vitals-
GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
Rectal exam:
EXTREMITIES: no edema +edema
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal
LABS:
N= B= AG= LFT
Blood Cx:
Urine Cx: , UA: , Sputum Cx:
Creatinine clearance=
ABG:
CPP x 1 - negative , BNpep
CXR:
XR:
CT
EKG:
ASSESSMENT:
-SOB due to
*Pneumonia
Previous ABx Tx- Structural lung disease-
CAP severity score:
Age NH resident
Organ dysfunction- CA Liver CHF CVA Renal /\MS
RR>30 SBP <90>125 pH<7.35>250 Hct<30 -Tylenol 650 mg PO q 4-6 hr PRN pain or fever -Home meds -Heparin 5000 U SQ BID Signature: Created: 2/2005 Updated: 03/08/2007
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