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.
Hospitalist Inpatient Note
Seen and discussed Dr [Consultant name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**Background:**
[Mention previously diagnosed issues] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**Baseline:**
[Mention state, ambulatory or bedridden] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**Home Medications:**
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**History of Presenting Illness:**
[Mention details of admission] (Only include if explicitly mentioned as HPI or history of presenting illness in transcript, contextual notes or clinical note; otherwise omit completely.)
**Subjectively:**
[Patient symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**Objectively:**
[Mention examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**Labs:**
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**Imaging:**
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**Assessment:**
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**Plan:**
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