SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough or sputum. (Abnormal: productive cough, green sputum. Dyspneic on exertion). GASTROINTESTINAL: Poor appetite. No nausea, vomiting or diarrhea. No abdominal pain or blood. Last BM yesterday 07/018/2017 soft, formed, brown. GENITOURINARY: No dysuria, frequency, urgency, retention, or blood. Last menstrual period, 07/08/2017. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. (Abnormal: pressure to generalized head). MUSCULOSKELETAL: No muscle pain, back pain, joint pain or stiffness. (Abnormal: c/o back pain around ribs region that is reproducible and worse with deep breathing and coughing). HEMATOLOGIC: No anemia, bleeding or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety (Abnormal: Anxiety. Depression. Denies suicidal/homicidal ideations. No previous psychiatric hospitalizations.) ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema or rhinitis (Abnormal: PCN-urticarial rash). O. Vital signs: Temp 99.4⁰F (37.4⁰C). BP 126/62 mm Hg. Pulse 72 bpm (sitting), regular rhythm. Resp 22/min. Pulse ox 96% on room air, at rest. Physical Exam: General: Appears stated age. Well-developed/nourished. HEENT: Tympanic membranes pearly gray w/ landmarks visible and intact; no discharge; mucosa pink without lesions; tonsil 1+ without exudate; no lymphadenopathy. (Abnormal: sinus congestion/pressure). Skin: Pink, warm, dry. Good skin turgor. No rashes, vesicles or other abnormal findings. Respiratory: Breath sounds clear in all fields; no adventitious sounds. Regular rate and rhythm, no accessory muscle use. (Abnormal: slight insp/exp wheezes to right lower lobe).
Cardiovascular: Regular rate (72 bpm) and rhythm when sitting, S1 and S2 are not accentuated or diminished, no extra sounds. All pulses present, 2+ and equal bilaterally. Carotids 2+ with no carotid bruit. Abdomen: Bowel sounds active in all quadrants. Abdomen soft, non-tender to palpate. No enlargement of liver or spleen. Diagnostic results : None available. In summary, our patient has been suffering from a cough, headache, and back pain, progressively getting worse over the past week. She reports a productive cough with green sputum and increased dyspnea on exertion. The pain in her back is located around the right side of her ribs and is reproducible and worsens with coughing or deep breathing. On physical assessment, we have found that she also has a low-grade temperature and wheezes can be heard in her right lower lung bases. She is also slightly tachypneic. For these reasons and more I believe the best course of action would be to do a 2-view chest x-ray, as well as a basic CBC, CMP, and possible blood cultures. I am anticipating her chest x-ray to show a right lower lobe consolidation, or pneumonia. If this is the case I would treat this patient with Levaquin 750mg PO daily x 5 days. “A high-dose (750 mg), short-course (5 days) of once-daily
- Fall '15