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Patient Chart Medical History
History of rheumatic fever with resulting cardiac valve damage. Nurses Notes: 2300: Patent brought to emergency department by their friend. Patient reports intermittent low-grade fever and anorexia. Manifestations presented a few days after having dental work performed. Now they are worse. Patient noticed shortness of breath with exertion today. Patient in semi-reclining position. Respirations easy and unlabored while at rest. Mild dyspnea observed when patient ambulated to the room. Lung sounds with fine rales in upper lobes bilaterally. Oral mucous membranes pink with petechia noted. Patient reports diffuse joint pain as 2 on a scale of 0 to 10. 2400: Patient restless and sweating, sitting in high-Fowler's position. Dyspnea noted at rest. Patient reports pain in mid-chest as dull, aching, and as 2 on a scale of 0 to 10. Few coarse rales auscultated bilaterally. Vitals: 2300: Blood pressure 120/78 mm Hg Apical pulse rate 110/min Respiratory rate 20/min Temperature 101.5F Oxygen saturation 98% on room air 2400: Blood pressure 112/64 mm Hg Apical pulse rate 128/min Respiratory rate 28/min Temperature 102.2F Oxygen saturation 95% on room air. can you prioritized this from 1to 3. fever, tachycardia, rales in the lungs
Patient is a 36 year old African American male, seen today for an initial outpatient psychiatry evaluation.
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