CC: Recurrent pneumonia.
History of Present Illness: Mr. Cauley is a very pleasant 56-year-old gentleman who has multiple pneumonias over the last year and one prior pneumonia in 2013. He has been hospitalization recently at Portsmouth Regional Hospital for a right-sided pneumonia was treated with antibiotics and he had rapid resolution of his symptoms associated with radiographic resolution. In February of this year, he suffered a similar episode of cough, fevers, and chills, which was again, at the time, treated with antibiotic therapy alone. Recently, he was evaluated in David Itkin 's, MD office where a workup for immuno compromising conditions was initiated. It should be noted Mr. Cauley suffered acute renal failure requiring …show more content…
Pulse 65. Blood pressure 122/66. O2 sat 97% on room air.
General: Well developed. Well nourished. No apparent distress. Appears stated age.
HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular muscles intact. Sclera anicteric without injection. Oropharynx without any lesions.
Mucous membranes moist.
Neck: Supple. No JVP. Trachea midline.
Lymph Node: No cervical or supraclavicular lymphadenopathy.
Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Symmetric chest expansion. Breathing nonlabored.
Heart: Regular rate and rhythm with normal S1, S2.
Abdomen: Soft, nontender and nondistended. Normoactive bowel sounds.
Extremities: No clubbing, cyanosis, or edema. Right arm is notable for a fistula with a palpable thrill.
Skin: No obvious rashes.
Neurologic: Alert and oriented. No gross focal neurologic deficits.
Psychiatric: Normal mood and affect.
Imaging: CT scan of the chest dated August 2015, which was compared to a prior CT in July 2015 as well as an additional CT scan in 2013. There is marked improvement in the appearance of the lungs when compared to previous study. There is only a small area of atelectasis or fibrosis in the right middle lobe. Prior study in 2013 demonstrates a fair amount of air space disease in the left
History of Present Illness: Mr. Cauley is a very pleasant 56-year-old gentleman who has multiple pneumonias over the last year and one prior pneumonia in 2013. He has been hospitalization recently at Portsmouth Regional Hospital for a right-sided pneumonia was treated with antibiotics and he had rapid resolution of his symptoms associated with radiographic resolution. In February of this year, he suffered a similar episode of cough, fevers, and chills, which was again, at the time, treated with antibiotic therapy alone. Recently, he was evaluated in David Itkin 's, MD office where a workup for immuno compromising conditions was initiated. It should be noted Mr. Cauley suffered acute renal failure requiring …show more content…
Pulse 65. Blood pressure 122/66. O2 sat 97% on room air.
General: Well developed. Well nourished. No apparent distress. Appears stated age.
HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular muscles intact. Sclera anicteric without injection. Oropharynx without any lesions.
Mucous membranes moist.
Neck: Supple. No JVP. Trachea midline.
Lymph Node: No cervical or supraclavicular lymphadenopathy.
Lungs: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Symmetric chest expansion. Breathing nonlabored.
Heart: Regular rate and rhythm with normal S1, S2.
Abdomen: Soft, nontender and nondistended. Normoactive bowel sounds.
Extremities: No clubbing, cyanosis, or edema. Right arm is notable for a fistula with a palpable thrill.
Skin: No obvious rashes.
Neurologic: Alert and oriented. No gross focal neurologic deficits.
Psychiatric: Normal mood and affect.
Imaging: CT scan of the chest dated August 2015, which was compared to a prior CT in July 2015 as well as an additional CT scan in 2013. There is marked improvement in the appearance of the lungs when compared to previous study. There is only a small area of atelectasis or fibrosis in the right middle lobe. Prior study in 2013 demonstrates a fair amount of air space disease in the left