DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Febrile illness, chest congestion, cough and weakness.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presented to the emergency department this evening accompanied by her daughter for evaluation of febrile illness, which has been present for the past 24 hours. She noted onset of chest congestion and productive cough this morning. She noted some yellow-colored sputum production. She denies any associated chest pain or shortness of breath. She has noted some increased fatigue and weakness. The daughter also indicates some increased confusion.
REVIEW OF SYSTEMS: The patient notes fever and chills. Denies any nausea, vomiting or diarrhea. She denies any dizziness or blurred vision. Does note some vague headache pain. She denies any ear pain, red, itchy or watery eyes as well as any sinus pressure, congestion or postnasal drainage. She denies any sore throat pain or difficulty swallowing. She denies neck pain, stiffness. Does note chest congestion, productive cough with sputum production as noted above. She denies any wheezing, diaphoresis, palpitations or abdominal pain as well as any back pain but does note some urinary frequency and urgency, but no dysuria. She denies any swelling to her extremities, numbness, tingling or paresthesias to the same. She denies any recent significant weight gain or weight loss. Remainder of review of systems was reviewed and was negative.
PAST MEDICAL HISTORY:
1. Non-insulin-dependent diabetes.
2. Hypertension.
PAST SURGICAL HISTORY:
Left below-the-knee amputation.
CURRENT MEDICATIONS:
1. Aspirin.
2. Metformin.
3. Labetalol.
4. Lisinopril.
5. Glipizide.
6. Gabapentin.
7. Norvasc.
ALLERGIES: No known drug allergies.
IMMUNIZATION HISTORY: Not applicable.
SOCIAL HISTORY: The patient is a nonsmoker. Denies any history of substance or alcohol abuse. She lives alone.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 101.4, pulse 108, respirations 18, BP 186/90, pulse oximetry 95% on room air.
GENERAL: A well-developed, well-nourished, nontoxic, nonambulatory (XX)-year-old female.
MENTAL STATUS: The patient is alert, oriented x3. Glasgow coma scale is 15.
HEENT: Normocephalic, atraumatic. Ears, eyes, nose, throat all within normal limits. Mucous membranes are moist, somewhat pale. Sclerae anicteric.
NECK: Supple, nontender, no meningismus. Trachea midline. There is no palpable evidence of thyroid anomaly, jugular venous distention or carotid bruits bilaterally.
LYMPHATICS: The patient exhibits no lymphadenopathy.
CHEST: Examination of the chest reveals equal bilateral breath sounds with evidence of rales noted in the left lower lobe. No evidence of wheezes, rhonchi or pleural friction rub. She otherwise exhibits normal chest wall excursion.
CARDIOVASCULAR: Tachycardic but otherwise regular rhythm without murmur, rub or gallop.
ABDOMEN: Benign.
BACK: Deferred.
RECTAL: Deferred.
PELVIC: Deferred.
EXTREMITIES: Reveals full range of motion of all extremities without deficit. This is with the obvious exception of the left lower extremity, which is absent following BKA. She otherwise exhibits strong distal pulses, brisk capillary refill in all of her remaining extremities.
NEUROLOGIC: Reveals no gross motor or sensory deficits. The patient is alert, cooperative. She exhibits intact distal sensation in all remaining extremities.
SKIN: Without diaphoresis, rash, lesions. Skin is warm and dry to touch with slight pallor but otherwise normal turgor.
DIAGNOSTIC DATA: CBC, blood cultures x2, urinalysis, urine culture, EKG and a chest x-ray PA and lateral were obtained. Sputum for culture and sensitivity and Gram stain were also obtained as well. CBC revealed elevated white blood cell count of 12,800 with a slight left shift. Differential revealed 87% neutrophils, no bands. H&H was otherwise within normal limits. Platelet count also was within normal limits. Basic metabolic panel revealed normal electrolyte balance. Serum glucose was elevated at 198 with normal BUN of 19 and elevated creatinine of 1.7. Blood cultures are pending. Urinalysis revealed trace ketones, small blood, greater than 300 mg protein, trace leukocyte esterase, negative nitrites. Urine sent for culture and sensitivity. Chest x-ray PA and lateral revealed evidence of left lower lobe infiltrate as reported by radiologist. EKG is pending. Sputum culture is pending.
EMERGENCY DEPARTMENT COURSE: Upon presentation to the ED, a saline lock was placed. The patient was given 1 gram of Tylenol p.o. She was started on fluids, 0.9 normal saline at 100 mL per hour and was given Avelox 400 mg IV piggyback. She has otherwise been stable throughout her stay in the emergency department.
PROCEDURES: None.
MEDICAL DECISION MAKING: Discussed this patient’s case with Dr. John Doe who also evaluated the patient. She agreed with the final diagnosis of left lower lobe pneumonia and the treatment plan that follows. This is a (XX)-year-old non-insulin-dependent diabetic female who presented to the emergency department today with febrile illness and focal left lower lobe infiltrate. Based on her history of present illness, results of diagnostic studies, pertinent clinical findings, believe that she can be safely treated on an outpatient basis. Emphasis will be on close outpatient followup. She will be instructed to return as well for any worsening symptoms or new concerns.
IMPRESSION: Left lower lobe pneumonia.
PLAN:
1. Rest, increase clear fluids.
2. Avelox 400 mg one p.o. daily, #10.
3. Tylenol every 4 hours, ibuprofen every 6 hours as needed for fever control.
4. Follow up with Dr. John Doe on Monday for reevaluation or return to the emergency department for persistence of fever, worsening symptoms or new concerns.
The patient voiced agreement with this treatment plan and voiced clear understanding of the instructions.
DISPOSITION: The patient was discharged to home in good condition.
