Doctoring Write-Up Patient Name: J.S.

Date/Writer: 9/4/13, 9:15am, John Smith AMS 2 Source: Patient, reliable historian CC: I cant stop coughing HPI: JS is a 34 year old female with no significant PMH who presents with 1 week of a productive cough. The patient recently traveled to Costa Rica with friends and noticed the cough. No one else is currently sick. She states the cough is intermittent throughout the day, worse at night. Nothing makes it better, but exerting herself makes it worse. She has never had a cough like this before and she describes the cough as sharp. She produces white sputum with her cough sometimes. She is concerned that she might have an infection and wants to feel better before her sisters wedding next week. JS denies nausea, vomiting, diarrhea, fever, or abdominal pain. PMH Childhood Illnesses: Multiple ear infections Adult Illnesses: None Hospitalizations: None Surgical History: Tonsils and Adenoids Removed, 1985 Medications: None Allergies: Penicillin (rash) FH Father: 50 (Type 2 Diabetes) Mother: 49 (Hypertension) Sister: 30 (Healthy) Children: None History of breast cancer on her fathers side of the family SH Patient works as a bank teller and reports happiness with her job. She enjoys traveling with her friends and currently denies financial or life stressors. She is not sexually active and is currently not in a relationship. She drinks 1-2 glasses of wine per week socially, but denies tobacco or illicit drug use. She lives alone in an apartment currently and runs 1-2 miles per week. ROS General: Patient denies fever, chills, night sweats, weight loss.

Skin: Denies rash or new lesions. HEENT: Denies nose bleeds, sore throat, neck pain. Neck: Denies lumps, or stiffness. Pulmonary: See HPI; denies, wheezing, hemoptysis, and pleuritic pain. Cardiovascular: Denies chest pain, irregular heartbeat. Digestive: Denies vomiting, constipation, diarrhea, change in bowel habits, rectal bleeding or jaundice. Genitourinary: Denies dysuria, nocturia, hematuria, incontinence, or groin pain. Musculoskeletal: Denies joint swelling, stiffness. Neurologic: Denies headaches, numbness, weakness, difficulty walking, tremors Hematologic/Lymphatic: Denies easy bruising, excessive bleeding, anemia, frequent infections. Psychiatric: Denies suicidal/homicidal thoughts, difficulty concentrating, or feeling down. Physical Exam General appearance: Well appearing female, appears stated age, comfortable, awake, alert. Vital Signs: Heart rate: 88 (regular) BP supine, L arm, 130/80, reg cuff BP sitting, R arm, 125/85, reg cuff Weight 130lbs Height 58 Temp 97.8F

BMI 22.5

Skin: No rash. Normal skin turgor. Head: NCAT Eyes: Conjunctiva clear, anicteric sclera, PERRLA, EOMI. Vision 20/20 both eyes with glasses, full visual fields to confrontation. Fundi: no hemorrhages or exudates; discs margins sharp. Ears: Bilateral ear canals clear. Bilateral tympanic membranes translucent, normal cone of light. Nose: No septal deviation mucosa normal. no polyps, discharge or sinus tenderness. Mouth: Mucous membranes moist, pharynx clear without exudate or swelling, good dentition. Neck: Supple, trachea midline. No thyroid nodules appreciated. No cervical, supraclavicular, auricular, submental lymphadenopathy. Cardiovascular: PMI 5th intercostal space, midclavicular line, well localized, no heaves, thrills. S1 normal intensity, A2>P2 with physiologic splitting. No gallops, clicks, murmurs or rubs. Capillary refill 3 seconds in bilateral hands. Carotids 2+ brisk upstroke, no bruits appreciated. Pulses are 2+ and symmetric in the bilateral radial, dorsalis pedis pulses. Pulmonary: Thorax symmetric, no increased AP diameter, no use of accessory muscles. Percussion resonant throughout. Auscultation reveals fine crackles in the RLL otherwise clear. Abdomen: Flat, soft, NABS in all quadrants. No TTP, guarding, or rebound. Liver percusses 10 cm in midclavicular line, firm, non-tender, no masses. No splenomegaly, renal artery bruits, CVA tenderness or shifting dullness appreciated. Musculoskeletal: Full range of motion of the shoulders, elbows, wrists, hands, hips, knees, ankles, and feet. No swelling appreciated. Neuro: Cranial nerves II-XII symmetric, intact. 5/5 strength in all 4 extremities. Sensation intact to light touch and sharp vs. dull throughout. Proprioception and vibration sense not tested. Cerebellar exam reveals normal finger to nose, rapid alternating movements, and heel to shin.

Gait evaluation reveals toe, heel, and tandem walk within normal limits. Reflexes are 2+ and symmetric in the biceps, triceps, brachoradialis, patellar, and Achilles tendons. Negative Babinski, no clonus bilaterally. Negative pronator drift and Romberg. Mental status: A&Ox3, normal affect. Folstein MMSE 30/30.

Assessment: 34 yr old female with no significant PMH who presents with 1 week of a productive, sharp cough without associated fever after traveling to Costa Rica with fine crackles in the RLL on exam, likely representing acute community acquired pneumonia.

Plan: 1. Will send patient for an outpatient chest xray today. 2. Start Tessalon Pearls 100 mg PO twice daily for cough. 3. Will obtain blood work today in the office including CBC and chemistry panel 4. If chest xray today reveals focal pneumonia, I will begin the patient on Levofloxacin 750 mg PO once daily for five days. 5. Patient will return in 5 days for a re-evaluation in the office before her sisters wedding.

.....John Smith, MD 9/4/13 9:30am Pager: 350-8047

Addendum: Chest xray results reveal a focal pneumonia in the right lower lobe as suspected. A prescription for Levofloxacin was sent to the patients pharmacy to begin today, 9/4/13. I called the patient at home to inform her of the results she is aware of the plan. .....John Smith, MD 9/4/13 5:20pm