CC: L.F. is a 20 year old male college student with a 2-week history of cough and increased sputum production who
presents to your clinic with new chest pain when he coughs, shortness of breath, intermittent fever and chills and blood-tinged sputum.
HPI: Cough treated with guaifenesin (Mucinex®) with dextromethorphan (Delsym®) obtained form roommate
Allergies: sulfa (nausea)
GEN: DOE and pleuritic chest pain
VS: BP 120/75 HR 95 T 100.5 RR 35 WT 90kg HT 6'4"
CHEST: LUL is CTA with significantly decreased breath sounds. There are E-to-A changes in the LLL and across the middle of the right lung field.
COR: tachycardic, no MRG
Chest X-ray: Consolidation of the inferior segments of the LLL. Remainder of the lungs are clear. Heart size WNL.
Questions to Answer in SOAP evaluation:
1. What would you prescribe for this patient to treat his infection, and what would you tell this patient about those medications (i.e. AE, monitoring of condition...)?
2. What other medications would you prescribe for this patient?
3. How would you follow-up with this patient (i.e. under what circumstances would you see him back)?