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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