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DAP NOTE
DATA
Subjective Patient complains of SOB, fever, and cough with green sputum. BP
168/88; P 88; T 103F/39.4C; R 20 and labored. Diminished breath sounds, e-to-a
changes and increased tactile fremitus over the left lower and middle lung fields,
2+ pedal edema. Sputum Gram stain shows gram-positive cocci in pairs. WBC 16.0
× 103 /mm3 with 12% bands, INR 3.5. Blood glucose and HbA1c elevated. Chest xray indicates cardiomegaly and left lobe infiltrate.

Assessment
1. Community-acquired pneumonia: probably pneumococcal in origin.
Azithromycin appears to be unnecessary without indication for atypical
pneumonia.
2. Hypertension: currently untreated. BP of 168/88 would usually be classified as
isolated systolic HTN, but present measurements may reflect infection and fever.
The heart rate of 88 while on metoprolol and digoxin is a relative tachycardia,
assuming that in the baseline environment the drugs would achieve a HR of 60 to
80 bpm.
3. CHF: Pedal edema and cardiomegaly on chest x-