Map concept

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