Subjective Rm. # RCP230 PART Age: 79 1 Male Female Dx: Cough, fever, RLL infiltrate Hx: Worked for a dry-cleaning chemicals company 51 years. 130 pack years Drinking habit Admitted 2 yrs ago for acute inferior myocardial infarctions. Objective Vital Signs: RR HR BP 33 120 165/90 Temp SpO2 O2 39.5 ˚C 87% 2 L/min Use of accessory muscles? Yes No Pursed Lip Breathing? Yes No Cough: Hacking Strong Weak Unable Sputum Production: Yes No Swallowed Sputum Characteristics:Small Amount Thick Thin Frothy Tenacious Color: White and Yellow Breath Sounds: RUL LUL RML Home Medications: N/A Student Tamer Fahel RLL Bronchial, dull percussion, increased tactile/vocal fremitus Date 5/11/20 Chief Complaint On Admission: Flu-like symptoms, cough, SOB, fever. ABG pH 7.56 HCO3 22 Hematology WBC 21,000 LLL PaCO2 24 SaO2 87% PO2 56 BE N/A RBC N/A HCT N/A Assessment Pt experiencing “flu-like” symptoms. He had chills, a mild fever, and a hacking, nonproductive cough. Pt symptoms worsened, was very short of breath, his cough was more frequent, and he had a temperature of 38.3C (101F). Pt had a frequent, strong cough. His cough was hacking and productive of a small amount of white and yellow sputum. His skin appeared pale and damp. When the man repeated the phrase ninety-nine, increased tactile and vocal fremitus was noted over the right lower lung posteriorly. Dull percussion notes and bronchial breath sounds were noted over the right lower lung regions posteriorly. His chest x-ray demonstrated a right lower lobe infiltrate consistent with pneumonia (air bronchograms, and alveolar consolidation). Plan Doctor’s Plan: Switch pt to HFNC and administer breathing treatment. Based on the increased WBC count start pt on antibiotics Suggestions To Doctor’s Plan: Suggest therapy to help drinking addiction *identify the patient and reason for admission Other: Pale skin, His chest x-ray demonstrated a right lower lobe infiltrate consistent with pneumonia (air bronchograms, and alveolar consolidation). *list medications and therapy, make suggestions if needed *observations, labs, X-ray, etc. *interpret objective information SOAP FORM FOR BASIC PATIENT ASSESSMENT
