E. S. Is a very pleasant 90 year old female presenting to the clinic today with the complaint of recent
community acquired pneumonia that resulted in hospitalization. She was taken to the ER on 08/20/014 with
complaints of severe dyspnea and cough. She was diagnosed with bilateral pneumonia and was placed in
the hospital for oxygen, breathing treatments, and antibiotics. She was discharged on 8/24/2014 with home
oxygen and three additional days of Levaquin PO and presents today for a follow up evaluation. Today she
presents on 3L of oxygen and denies any chest pain, shortness of breath, fever, chills, or fatigue. She does
complain of a mild productive cough with white sputum.
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other
related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
