Community-Acquired Pneumonia (demo)

H&P · Preview encounter

Maria R.

62 female · she/herurgent
MRN
FP-0002
Room
208
Attending
Dr. Elaine Cho
Resident
Dr. Marcus Webb
RN
Josephine Diaz, RN

Reason for visit Shortness of breath and productive cough · inpatient

NKDAFull CodeDroplet

Vitals

Most recent · Day 1 09:15

Temp

38.2°C

HR

104

RR

22

BP

128/78

SpO₂

94% on 2L nasal cannula

HR

104118

HIGH
112118104

RR

2228

HIGH
242822

Temp

38.2°C38.8°C

HIGH
38.638.838.2

SpO2

84%94%

898494

BP systolic

126128

128126128

BP diastolic

7678

787678

Active Problems

  • Hypertensionactive
  • Type 2 diabetes mellitusactive

Allergies

No known drug allergies.

Home Medications

  • Metformin 500mg · PO · twice daily
  • Lisinopril 10mg · PO · daily

Care Team

Attending
Dr. Elaine Cho
Resident
Dr. Marcus Webb
Nurse
Josephine Diaz, RN
Room
208