Medical Record For Joe Hardy
Patient Information
Joe Hardy
DOB:
3/17/1952
Sex:
Male
Gender Identity:
Male
MRN:
843201
Weight:
180 lbs or 81.65 kg
Admitting Diagnosis:
Pneumonia, left lower lobe
Admitting Physician:
Michael Stark, M.D.
Past Medical History
Allergies
Amoxicillin (Hives)
Medical Problems
Hypertension (HTN), lung cancer
Surgical History
Status Post right upper lung lobe resection in 2014
Social History
Widowed. Lives alone in an assisted living facility. Former smoker. Quit 10 years ago when diagnosed with lung cancer. Does not drink and denies drug use. Retired police chief. Has two adult children, Sam and Sara. Both alive and well.
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0830 | Michael Stark, M.D. | 72yo male, AAOx4 Presented to the emergency department with shortness of breath with productive cough and fever x 2 days. Sputum is moderately thick, yellow-green in color, no blood. Maximum temperature at home 101.5 degrees. Admitted for antibiotics and further monitoring. |
Vital Signs
| Time | 0830 |
|---|---|
| Heart Rate | 116 |
| Blood Pressure | 146/82 |
| Respiratory Rate | 18 |
| Pulse Ox | 96% on Room Air |
| Temperature | 101 F Oral |
| Pain | 4/10 |