Pneumonia

HISTORY:

‍CoughFeverDifficulty breathing for ‍ ‍hoursdays

‍cough, ‍non-productiveproductive

‍sputum, ‍clearcolored

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍shortness of breath

‍chest pain, ‍retrosternal, ‍on exertionat restwith deep breath

‍fatigue

‍loss of appetite

‍confusion

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍no rash



ASSESSMENT:

‍Pneumonia ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Chest X-ray

- Blood work: ‍CBC, ‍CRP, ‍electrolytes, ‍creatinine, ‍blood cultures

- Sputum culture

- CT scan of the chest

- Oxygen therapy if SpO2 < 92%

- ‍Oral antibiotics

- ‍Acetaminophen

- ‍Ibuprofen

- Hydration and rest

- Smoking cessation counseling

- Vaccination for ‍pneumococcus, ‍influenza, ‍covid

- Repeat chest X-ray in 6 weeks

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if new symptoms develop

- Go to ER if severe chest pain, severe shortness of breath, or high fever occurs