RESPIRATORY

HPI: 34 YO MALE C/O CHEST AND COUGH. 2 DAYS AFTER HE WAS

STANDING IN THE RAIN FOR OVER AN HOUR.. CHEST PAIN IS SUBSTERNAL,
BEGAN 2 DAYS AGO, 8/10 INTENSITY, SHARP, CONSTANT, PROGRESSIVELY
WORSE NON RADIATING,.
-AGGRAVATING: COUGH, MOVEMENT INSPIRATION
-ALLEVIATING: LYING DOWN AND CARBONATED DRINKS
-ASSOCIATED: PATIENT REPORTS SHORT OF BREATH, NOCTURNAL
DYSPNEA, COUGH WITH THICK GREENISH SPUTUM, TEASPOON OF BLOOD,
NO ODOR, POSTNASAL DRIP, SORE THROAT, DIFFICULTY BREATHING,
WEAKNESS IN ALL FOUR EXTREMITIES, RECENT FEVER, CHILLS AND NIGH
SWEATS. DID NOT TAKE HIS TEMPERATURE, BUT FEELS HOT.
-PATIENT DENIES: BOWEL OR BLADDER CHANGES, TB OR SICK CONTACTS,
TRAVEL, DIARRHEA OR VOMITING, RASH, EDEMA OR ABDOMINAL PAIN.
PATIENT DENIES HISTORY OF STDS. NO WEIGHT OR APPETITE CHANGES

ROS: NEGATIVE EXCEPT AS NOTED ABOVE

ALLERGIES: PENICILLIN, REACTION UTICARIA
MEDICATIONS: NONE
PMH: NONE, NO PREVIOUS EPISODES
PSH: NONE
SH: PATIENT DENIES TOBACCO, ETOH, DRUG USE, WORKS AS A
CONSTRUCTION WORKER, LIVES WITH FIANCÉ, USES CONDOMS
FH: PARENTS ARE ALIVE AND WELL

PHYSICAL EXAM
GA: PATIENT IS IN NO ACUTE DISTRESS
VS: WNL
HEENT: NOSE MOUTH AND PHARYNX WNL
NECK: NO JVD NO LYPHADENOPATHY
HEART: APICAL IMPULSE NOT DISPLACES, RRR, S1 S2 NORMAL, NO
MURMURS, RUBS OR GALLOPS.
CHEST: INCREASED RESPIRATORY RATE, DECREASED BREATH SOUNDS
BILATERALLY, +WHEEZING, NO RHONCHI OR RALES
EXT: NO EDEMA, NO CYANOSIS, NO CLUBBING

DD:
PNEUMONIA
URI POST INFECTIOUS
ASTHMA EXACERBATION
ACUTE BRONCHITIS
ATYPICAL PNEUMONIA
WORK UP:
CBC/ UA/ABG
CHEST RAY
CT CHEST
SPUTUM AND GRAM STAIN AND CULTURE
PULSE OXIMETRY