A 54-year-old patient presents with a productive cough for 7…
A 54-year-old patient presents with a productive cough for 7 days. On examination: temperature 101.2 °F (38.4 °C), respiratory rate 22/min, heart rate 104/min, oxygen saturation 93% on room air, and crackles in the right lower lung field. No chest imaging has yet been obtained. Which statement is the most appropriate assessment entry in the SOAP note?
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