Chapter 9: The Respiratory System | David Marino's Chart Note

CHART NOTE

Patient Name: Marino, David
ID Number: DMM1782
Examination Date: September 7, 20xx

SUBJECTIVE
David is a 17-year-old high school student who complains of shortness of breath and sudden chest pain during lacrosse practice.

OBJECTIVE
Patient presents with pronounced dyspnea and elevated pulse and BP. Temperature is 101. The pharynx is clear. The right lung shows decreased breath sounds with air exchange. Chest X-ray reveals a collapsed lower lobe of the right lung.

ASSESSMENT
Pneumothorax due to blunt force rib fracture.

PLAN
Inserted chest tube to reinflate lung. Patient is stable and will be transferred by ambulance to General Hospital.