Executive Solution Overview
Marian is a 43-year-old Asian female who presents to your outpatient clinic with complaints of fever and productive cough. – Denies tobacco and drug use – Negative medical history – Family history positive for cardiovascular disease in her father – Reports a fever (max temp 101 F), fatigue, generali…
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Marian is a 43-year-old Asian female who presents to your outpatient clinic with complaints of fever and productive cough.
– Denies tobacco and drug use
– Negative medical history
– Family history positive for cardiovascular disease in her father
– Reports a fever (max temp 101 F), fatigue, generalized muscle aches, and productive cough of green sputum x 5 days
– Starting today, Marian has developed shortness of breath with minimal activity.
Review of systems:
– VS: Temp 101.1 F, HR 94 bpm, RR 32 breaths/min, BP 92/48 mm Hg, SaO2 91% on room air
– **General**: Appears stated age; speech clear
– **Skin:** warm to touch; pallor present
– **HEENT:** Nasal congestion present
– **Respiratory:** crackles (rales) auscultated bilaterlly in lower lobes, positive use of accessory muscles at rest, tachypnea, dyspnea with exertion
– **Cardiovascular:** S1 and S2 auscultated, no murmurs present. Denies chest pain.
– **Gastrointestinal:** bowel sounds auscultated in all quadrants; abdomen soft and nontender
– **Genitourinary:** Denies dyruria
– **Musculoskeletal:** No edema of extremeties. Strength 5/5 in bilateral upper and lower extremities.
– **Neurological:** alert and oriented x 4; PERRLA
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