Patient ID: 3483758

Admission Date: 2/13/XX                

DOB: 8/20/XX

Chief Complaint: SOB, Coughing

 

History of Present Illness: Mr. Wells is a 52 year old male who presented to the ER with 105 degree temperature, SOB and Productive cough.  He was admitted to the medical-surgical unit.

 

Medical History:  HTN, hypercholesterolemia, 

 

Medications: Dyazide, Lipitor, Colace

 

Allergies: Demorol, Erythromycin

 

Social History: He does not drink and smokes 1 pack/week

 

Family History: Married with 2 children.  Father died of MI. 

 

Physical Examination:

General:  This is a overweight male who is alert and oriented x 3

Diet: Reg Diet

Vital Signs: Blood Pressure 110/88, heart rate 88, Respiration 26, Temperature 105.2°F

HEENT: Clear

Lymph: Unremarkable

Neck: No goiter, no jugular venous distention

Chest: Crackles

Heart: Regular rate and rhythm, no murmur, rub or gallop

Abdomen: Soft and nontender

Genitourinary: nontender

Rectal: Unremarkable.                                   

Skin: pink, moist mucous membranes. Skin turgor within normal limits.

 

Laboratory and X-ray Data: sodium 140, Potassium 3.8, glucose 90, BUN 15, creatinine 1.0, white count 12000, Hemoglobin 14.2, Hematocrit 45, platelets 210.  CXR evidence of pneumonia

 

Impression:

  1. Pneumonia

 

Plan:

  1. Admit for antibiotic therapy
Last modified: Monday, March 23, 2020, 11:36 AM