Clinical note · #30
Office & outpatient
Patient: Daniel Foster
Age: 52
Place of Service: Office – Outpatient
Chief Complaint: Fever, productive cough, and shortness of breath for 4 days.
History of Present Illness (HPI):
The patient presents for evaluation of fever, productive cough, and worsening shortness of breath for the past four days. Symptoms began abruptly with chills and generalized body aches and have progressively worsened. He reports persistent fever at home with temperatures up to 102.1°F, associated with fatigue, malaise, and decreased appetite. He describes cough productive of yellow sputum and pleuritic chest discomfort with deep inspiration. He reports mild dyspnea with exertion but denies syncope, hemoptysis, nausea, vomiting, or confusion. These symptoms have interfered with his ability to perform normal daily activities. No recent hospitalizations are reported.
Review of Systems (ROS):
- Constitutional: Fever, chills, fatigue, malaise
- Respiratory: Productive cough, dyspnea on exertion
- Cardiovascular: Pleuritic chest discomfort; denies palpitations
- Gastrointestinal: Decreased appetite; denies nausea or vomiting
- All other systems reviewed and negative
Past Medical History (PMH):
- Hypertension
Medications:
- Lisinopril 10 mg daily
Allergies: No known drug allergies
Physical Examination:
- General: Alert, oriented, appears ill but not in acute distress
- Lungs: Decreased breath sounds with crackles at the right lower lung field
- Heart: Regular rate and rhythm
- Extremities: No cyanosis or edema
Diagnostic Data:
- Chest X-ray ordered and reviewed – right lower lobe infiltrate noted
Assessment:
Community-acquired pneumonia.
Plan:
- Assessment and imaging findings discussed with the patient
- Start azithromycin as outpatient antibiotic therapy
- Encouraged oral hydration and rest
- Acetaminophen as needed for fever
- Strict return precautions reviewed, including worsening dyspnea or persistent fever