Chief Complaint: Fever, chills, shortness of breath, and confusion.
History of Present Illness (HPI): Mr. John Smith is a 68-year-old male who presented to the emergency department with complaints of fever (102.5°F), chills, shortness of breath, and progressive confusion over the past 24 hours. Symptoms began after several days of fatigue and mild cough. Family members report that he has become increasingly disoriented and less responsive to questions.
Past Medical History (PMH):
Hypertension
Type 2 Diabetes Mellitus (diagnosed 10 years ago)
Chronic Kidney Disease, Stage 3 (baseline creatinine ~2.1 mg/dL)
Past Surgical History (PSH):
Appendectomy in adolescence
Cataract surgery (left eye) 2 years ago
Family History (FH):
Father: deceased (myocardial infarction at 72)
Mother: deceased (complications of diabetes)
Social History (SH):
Retired schoolteacher; lives with spouse
Non-smoker; occasional wine use
Denies illicit drug use
Allergies: No known drug allergies
Medications:
Lisinopril 20 mg daily
Metformin 500 mg BID
Atorvastatin 20 mg nightly
PHYSICAL (P)
Vital Signs:
BP: 90/55 mmHg
HR: 110 bpm
RR: 28 breaths/min
Temp: 102.5°F
O2 Sat: 88% on room air
General Appearance: Pale, diaphoretic, appears acutely ill. Alert but intermittently confused.
HEENT: Mucous membranes dry, pupils equal/reactive to light.
Cardiovascular: Tachycardic, regular rhythm. Peripheral pulses diminished.
Respiratory: Labored breathing, bilateral crackles at lung bases.
Gastrointestinal: Abdomen soft, non-distended. Bowel sounds present.
Genitourinary: No output at time of exam; Foley catheter not yet placed.
Neurological: Intermittent confusion; responds to simple questions but delayed.
Skin: Warm, diaphoretic. No rash or lesions noted.