Pulmonary Case Study

HISTORY AND PHYSICAL EXAMINATION

This 53-year-old male was evaluated by me in the emergency department on the above date, complaining of progressive shortness of breath and weakness.  He allegedly had been treated some 1 week prior for a right-sided pneumonia, being placed at that time on tetracycline 250 mg q.i.d., promethazine 6.25 mg every 4 hours, and Tylenol 1 every 3 to 4 hours as needed for temperature.  Historically, he has been coughing, nonproductive in nature, and has been experiencing fever and chills.  He had taken a Tylenol approximately an hour and a half prior to this evaluation.  He also has been experiencing poor appetite.

PHYSICAL EXAMINATION

VITAL SIGNS:  Physical assessment reveals his respiratory rate to be 48 per minute, pulse of 112, temperature 99.8, and a blood pressure of 150/80.

GENERAL:  General assessment reveals him to appear somewhat dehydrated, characterized by having dry mucous membranes.

NECK:  There is no nuchal rigidity.

ENT:  Ears, nose, and throat examinations were otherwise unremarkable.

HEART:  His heart rate was regular and rapid without any definite murmurs, S3, or S4.

LUNGS:  Lungs were noted to have rales in the anterior and posterior inferior aspects with decreased breath sounds noted to those areas.  His left lung fields were within normal limits.

ABDOMEN:  His abdomen was soft, nontender, with bowel sounds.

GENITALIA/RECTAL:  Genital and rectal examinations were deleted.

EXTREMITIES:  His extremities were found to be free of any exanthematous changes.  His nail bed color was considered satisfactory.

PLAN

While in the emergency department, multiple diagnostic studies were performed, including a CBC which revealed a white blood count of 18,800, 83 segs, 4 bands, 7 lymphs.  Arterial blood gas revealed a pH of 7.46, PC02 of 40, and a PO2 of 65.  Additional studies pending at this time were a Panel A and a sputum culture and sensitivity.  Chest radiograph obtained and initially interpreted by me revealed consolidative change involving the entire right lower lobe.

IMPRESSION

Right lower lobe pneumonia, refractory to outpatient therapy.

FOOTNOTE

Line 12 (Page 1).  Alternative:  3-4.  Alternative:  Change temperature to fever.  (Technically, everyone has a temperature and Tylenol is taken for a fever.  However, the physician’s use of temperature in the context is perfectly understood.)

Line 18 (Page 1).  The heading Physical Examination was added.

Lines 19-36 (Page 1).  The subheadings were added in the Physical Examination.

Line 27 (Page 1).  The plural forms were changed to singular because there is only one of each.

Line 33 (Page 1).  Exam was changed to examinations for
subject-verb agreement.