Doctor Aged Care

[Facility Name] The Meadows Care Home 01/11/2024 Patient Name: Mrs. Elsie May Billing Codes: Z71.1, I10 History: - History of presenting complaint: Mrs. May presents today with a worsening cough and increased shortness of breath over the last week. She reports feeling fatigued and has a loss of appetite. - Past medical history, previous surgeries: Mrs. May has a history of hypertension, managed with medication. She had a hip replacement five years ago. - Medications and herbal supplements: Mrs. May is currently taking Lisinopril 10mg daily. She also takes a multivitamin. - Social history: Mrs. May lives in the care home and is generally independent with activities of daily living. She has two children who visit regularly. On Examination: - Examination findings: Temperature 38.2°C, SpO2 92% on room air, auscultation reveals crackles in the right lung. Blood pressure 140/88 mmHg. Chest X-ray ordered. Plan: - Plan: Prescribe Amoxicillin 500mg three times a day for suspected pneumonia. Encourage rest and adequate fluid intake. Review in 2 days or sooner if symptoms worsen. Arrange for chest X-ray.