Date of birth: January,17 1986
Allergies: NKDA
Compliant: Fatigue, fever, and malaise for the past 3 weeks
History:-
Temperature: 101-104 in the past week
Temperature on admission: 100.2 orally
Taking acetaminophen and ibuprofen every 4-6 hours at home
Medical history: Pre-hypertension and Raynaud’s disease
No past surgeries or medicine at home
Current:
BP=113/80
Temp=101
O2 sat=95%
HR=110
R=18
Labs:
PH=7.2
Lactate=7
WBC=
Blood Cultures=
Chem 7=