Lesson 1. Admission EHR — simulated electronic medical record for Roberto Delgado

Mr. Delgado arrived to the med-surg unit from the ED, accompanied by his wife, Elanore, who remained at the bedside. Received alert, oriented ×3, cooperative, and appropriately conversant; appears tired and mildly anxious but in no acute distress. Reports mild chest discomfort with cough and ongoing fatigue. Settled into room, oriented to unit, call light within reach.

Vitals on arrival to unit: Temp 101.4°F (38.6°C) · HR 98 · RR 22 · BP 134/84 · SpO₂ 93% on room air · Pain 2/10 with cough.

Patient: Roberto Delgado · 68 yo male · Admitting diagnosis: Community-acquired pneumonia (CAP) · Allergies: Penicillin (rash)

Chief Complaint: “Cough and fever that won’t quit” — three days, brought in by his wife.

History of Present Illness: Mr. Delgado is a 68-year-old man with type 2 diabetes, hypertension, and a ~30 pack-year smoking history (quit 5 years ago) who presents with three days of progressively worsening productive cough, subjective fever, and generalized fatigue. Symptoms have escalated to the point that his wife, Elanore, brought him in for evaluation. In the ED he was febrile to 101.8°F, tachycardic (HR 102), tachypneic (RR 24), and borderline hypoxemic at 92% on room air, with mild chest pain (3/10) associated with cough. He is alert, oriented, and cooperative, appearing tired and mildly anxious but in no acute distress. Notably, he tends to minimize his symptoms and voiced concern about “being a burden,” so his reported discomfort likely understates his true clinical picture. Presentation is consistent with community-acquired pneumonia.

Past Medical History: Type 2 diabetes mellitus (diet-controlled + metformin), hypertension, mild bilateral knee osteoarthritis.

Social History: Retired high-school teacher. Lives with his wife; two adult children nearby. Bilingual (English/Spanish). Former smoker (~30 pack-years, quit 5 years ago). No current tobacco use noted. Enjoys gardening and cooking.

Family History: Non-contributory to current presentation.

Allergies: Penicillin — rash.

Review of Systems: Positive for cough, fever, fatigue, mild pleuritic chest pain, and mild dyspnea. Denies (per report, corroborate given under-reporting tendency) chest pressure, hemoptysis, syncope, or GI symptoms.

Vital Signs (on admission): Temp 101.8°F / 38.8°C · HR 102 · RR 24 · BP 138/86 · SpO₂ 92% RA · Pain 3/10. (Baseline well: ~130/80, HR ~74, RR ~16, SpO₂ ~97% RA — current values reflect acute illness.)

Physical Exam:

General — tired-appearing, mildly anxious, no acute distress, conversant.
HEENT — normocephalic, mucous membranes slightly dry.
Cardiovascular — mild tachycardia, regular rhythm, no murmur.
Pulmonary — tachypneic; anticipate focal crackles / decreased breath sounds over the affected field (confirm on exam and correlate with imaging).
Abdomen — soft, non-tender.
Neuro — alert and oriented ×3, no focal deficits.
Skin — warm; no rash.

Assessment: 68-year-old man with CAP, hemodynamically stable but with high-risk vital signs (tachycardia, tachypnea, borderline hypoxemia) and diabetes as a complicating comorbidity. Triaged ESI 2. At risk for deterioration / impaired gas exchange; his tendency to under-report warrants close monitoring rather than reliance on self-report.

Plan:

• Pneumonia: Empiric CAP antibiotics per guideline — avoid penicillins / beta-lactams given allergy; select an appropriate non-penicillin regimen (e.g., respiratory fluoroquinolone, or per stewardship). Obtain chest imaging, CBC, chem panel, blood / sputum cultures; consider procalcitonin / lactate.
• Oxygenation: Continuous pulse oximetry; supplemental O₂ to keep SpO₂ ≥ 92–94%. Monitor respiratory status closely.
• Diabetes: Hold metformin during acute illness; sliding-scale insulin and monitor glucose.
• Hydration / monitoring: IV fluids as needed.
• Supportive: Antipyretics, pulmonary hygiene, ambulation as tolerated.
• Communication: Reassure re: “burden” concern; involve Elanore and offer Spanish-language support as requested.

Disposition: Admit to med-surg.

Mr. Delgado is a patient brought to the ED by his wife with a three-day history of progressively worsening productive cough, subjective fever, and generalized fatigue. He is alert, oriented, and cooperative on exam, appearing tired and mildly anxious but in no acute distress. Clinical presentation is consistent with community-acquired pneumonia (CAP), and workup including chest imaging, labs, and cultures was initiated in the department. Given his symptom progression and need for supportive care, he is being admitted to the medical-surgical unit for IV antibiotics, monitoring, and continued management.