Patient: E.L.

Subjective:
54 y/o white male with no nausea or vomiting, no constipation or diarrhea
this morning. Patient complained about a fever with chills at about 10 am
this morning. He is eating properly and tolerating intake well. Patient has no
complaints of dysuria or abdominal pain. He says his last bowel movement
was 1 day ago. The patient is still coughing, along with greenish sputum.
Patient has no wheezing, hemoptysis, orthopnea or paroxysmal nocturnal
dyspnea. Patient noted shortness of breath along with pain on the right side
during deep inspiration. Patient also complains of poor sleep.

Objective:
Physical Examination:
Vital signs:
o T: 100.2
o Maximum temperature: 102.6
o BP 128/82
o RR: 20
o HR: 98
General: Alert and oriented to person, place, and time, flushed, moderate
distress. Mucous membranes moist, fair skin turgor; well developed/well
nourished.
Head: normocephalic/atraumatic
Eyes: pupils are equal, round, reactive to light, and accommodation).
Extraocular muscles are intact.
Ears: No erythema, no discharge, tympanic membrane intact.
Throat: No erythema or exudates. Tongue protrudes straight.
Neck: No nuchal rigidity, good range of motion; No
masses/lymphadenopathy
Cardiovascular: Regular rate/rhythm. S1/S2, no S3 or S4, no murmurs,
gallops, or rubs.
Pulmonary: + R lower lobe dullness to percussion; increased tactile fremitus,
increase breath sounds, noted whispered pectoriloquy; +fine crackles R
lower third posteriorly. No wheezes, rubs, or rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds noted, no rebound,
guarding, masses or hepatosplenomegaly; rectal exam positive for fecal
occult blood).
Extremeties: no clubbing, cyanosis, edema, 2+ dorsalis pedis, posterior tibial.
Neuro: cranial nerves intact
Labs: None

Assessment:
o 54 y/o white with community-acquired pneumonia.
o DM


Patient: E.L.
Plan:
o Pulmonary: Pneumonia, Continue
2 grams daily of ceftriaxone (Rocephin)
Codeine for pleuritic chest pain as needed
Tylenol for fever as needed.
o Endocrine: DM Type II Continue Glipizide once daily