Hospitalist trial

Hospitalist Inpatient Note Seen and discussed Dr. Eleanor Vance **Background:** Patient has a history of hypertension and type 2 diabetes. **Baseline:** Patient is ambulatory. **Home Medications:** * Lisinopril 20mg orally once daily * Metformin 500mg orally twice daily **History of Presenting Illness:** Patient presented to the emergency department with a three-day history of worsening shortness of breath and cough. Chest X-ray revealed bilateral pneumonia. Admitted for intravenous antibiotics and respiratory support. **Subjectively:** Patient reports shortness of breath, cough with some yellow sputum production, and mild chest discomfort. **Objectively:** * Temperature: 38.2°C * Blood pressure: 140/90 mmHg * Heart rate: 100 bpm * Respiratory rate: 24 breaths per minute * Oxygen saturation: 92% on room air * Lung auscultation: Bilateral crackles **Labs:** * White blood cell count: 14,000/µL * C-reactive protein: 120 mg/L **Imaging:** Chest X-ray: Bilateral pneumonia. **Assessment:** Community-acquired pneumonia. **Plan:** * Continue intravenous antibiotics (ceftriaxone and azithromycin). * Supplemental oxygen to maintain saturation >90%. * Monitor vital signs and respiratory status. * Repeat chest X-ray in 48 hours. * Consult respiratory therapy for breathing exercises. * Review blood glucose levels and adjust diabetes medications as needed.