Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Cough (productive or non-productive, duration)
Fever (duration, chills)
Shortness of breath (onset, exertion-related)
Pleuritic chest pain (sharp, stabbing, worse with inspiration)
Malaise (general feeling of unwellness)
Other symptoms (sputum production, fatigue, headache)
II. History of Present Illness:
Gradual or sudden onset of symptoms?
Recent upper respiratory tract infection (cold, sinusitis)?
Risk factors for pneumonia (smoking, chronic lung disease, immunosuppression)
Prior hospitalizations for pneumonia
III. Past Medical History:
Underlying medical conditions (chronic obstructive pulmonary disease (COPD), asthma, heart failure, diabetes)
Smoking history (current smoker, former smoker, never smoker)
Immunizations (pneumococcal vaccination, influenza vaccination – dates if available)
Medication use (inhaled corticosteroids, antibiotics)
IV. Social History:
Living situation (crowded housing)
Occupational exposures (dust, fumes, irritants)
Travel history (recent travel can increase risk of atypical pneumonia)
Alcohol use
V. Physical Exam:
Vital Signs:
Temperature (oral, rectal, or tympanic)
Blood pressure
Heart rate
Respiratory rate (tachypnea may be present)
Oxygen saturation (hypoxemia possible)
General: Appearance of illness (mild, moderate, severe)
Respiratory:
Chest expansion (decreased on affected side)
Tactile fremitus (decreased or absent over consolidation)
Percussion (dullness over consolidation)
Auscultation (bronchial breath sounds, crackles)
Other:
Clubbing (杵状指; chùy zhuàng zhǐ) (fingers) – possible sign of chronic lung disease
VI. Assessment:
Community-acquired pneumonia (CAP) – suspected location (lobar, bronchopneumonia)
Severity assessment (CURB-65 score, pneumonia severity index) – helps guide treatment decisions
Possible causative organism (typical vs. atypical pneumonia)
VII. Diagnostic Studies:
Chest X-ray: (infiltrates, consolidation)
Sputum culture and Gram stain (identify bacteria)
Legionella and other atypical pneumonia testing (if indicated based on suspicion)
Complete blood count (CBC) with differential (elevated white blood cells suggest infection)
Blood cultures (may be ordered to identify bacteremia)
Arterial blood gas (ABG) – assess oxygenation status (if hypoxemia suspected)
VIII. Plan:
Treatment plan depends on severity, suspected organism, and other factors:
Antibiotic selection (broad-spectrum initially, narrow spectrum based on culture results)
Oxygen therapy (if hypoxemia present)
Respiratory support (nebulizer treatments, bronchodilators)
Antipyretics and analgesics (for fever and pain)
Chest physiotherapy (to mobilize secretions)
Hospitalization decision (based on severity, social factors)
Disposition plan (home with outpatient follow-up, transfer to skilled nursing facility)
IX. Follow-up:
Outpatient follow-up appointment in X days to monitor response to treatment and chest X-ray follow-up if needed.
Advise on signs of worsening that require urgent evaluation (increased shortness of breath, fever not responding to medication).
X. Notes:
Include any additional observations or concerns, such as response to initial therapy, potential complications (pleural effusion, empyema), and need for additional imaging (CT scan).
XI. Resources:
Consider providing patient education materials on community-acquired pneumonia, self-care measures, and importance of smoking cessation.