Examination
CC: repeated vomiting, weak, tired, light-headed, lost consciousness once, difficulties breathing, persistent cough, bronchopneumonia
PMH: Hypertension (treated), DM II on oral antidiabetics, depression,
DH: citalopram 20 mg 1-0-0, indapamide 2,5 mg 1-0-0, metformin 1000 mg 1-0-1, Amoxicillin-clavulanate 1 g Q8h (last 4 days, discontinued today)
Physical examination: vomiting during the examination, on pulmonary auscultation bilateral basal coarse crackles, abdomen on palpation painless, soft, without any resistance, on percussion physiological, on auscultation peristalsis in all four quadrants, per rectum without any pathological findings, no signs of peritoneal irritation, otherwise without anything noteworthy
Chest X-ray (AP projection, standing): Conslolidation in lower lobe bilaterally with visible air bronchogram (highly suspicious of bilateral basal bronchopneumonia), otherwise without anything noteworthy
Abdominal X-ray (AP projection, standing): Without signs of hydroaeric levels or pneumoperitoneum
Treatment plan: Cefotaxime 1 g/100 mL NS Q8h 30 min IV infusion + Clarithromycin 500 mg/100 mL NS Q12h 15 min IV infusion, metoclopramide 10 mg 3 min IV bolus, Oxygen O2 (nasal cannula) 2 L/min, acetaminophen 10 mg/mL 100 mL 15 min IV infusion (as needed)
