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S: Subjective
A 46-year-old simulated patient reports a productive cough for five days with yellow sputum and mild shortness of breath on exertion. Denies chest pain. Non-smoker. No known drug allergies.
O: Objective
Temperature 38.1 °C, heart rate 96, respiratory rate 22, blood pressure 124/78, SpO₂ 95% on room air. Coarse crackles in the right lower lobe that do not clear with coughing; increased tactile fremitus and dullness to percussion over the same area. No accessory muscle use.
A: Assessment
Findings localised to the right lower lobe (crackles, increased fremitus and dullness) together with fever and productive cough are consistent with consolidation. Oxygenation is currently adequate.
P: Plan
Report findings to the provider; anticipate chest imaging. Monitor respiratory status and SpO₂ every four hours; encourage fluids, deep breathing and coughing; reassess lung sounds after interventions. Document findings using consistent assessment terminology (Bickley et al., 2021).
Reference
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.
