Subjective
The patient reports 3 days of productive cough and fever, with right-sided chest discomfort on deep inspiration. No shortness of breath at rest. The patient reports no known drug allergies. (appears in this excerpt)
Objective
Temperature 38.2 °C, BP 124/78 mmHg, heart rate 96 bpm, SpO2 97% on room air. Crackles at the right lung base on auscultation.
Assessment
Probable community-acquired pneumonia, right lower lobe.
Plan
- Chest radiograph, PA and lateral, today.
- Amoxicillin 1 g every 8 hours for 7 days.
- Rest and oral fluids.
- Review in 48 hours, or earlier if breathing worsens.