Emergency Room Report.
Patient: Lodogod,Way James.
Sex : Male.
Triage time: 1850pm.
Acuity: Level 2
Chief Complaint :Difficult Breathing.
Diagnosis: Acute asthma exacerbation with pneumonia.
1850PM: BP 120/80,Hr: 76,Respiration 24,Temperature 98.2,02 Saturation 94%room air. Pulse oximeter applied.Alert and oriented ×4.
EMERGENCY MEDICAL SERVICE (EMS) treatment PTA (Prior to Admission)verbally communicated, Pulse oximeter applied,Cardiac monitor applied. Medication of Albuterol given 3times .Bp 150/79,Hr 102,RR 20 ,02 Saturation 93RA.
Weight 163Ibs,Height 5ft 4inches.
RN:Nicole Lovegod RN.
Medications Clarithromycin oral given at 1930pm by Nicole Lovegod,RN.
Albuterol- Ipratropium Inhalation at 1930pm by Nicole Lovegod,RN.
PMH: Coughing and wheezing ×3 days(Productive Coughing)Asthma, pacemaker,atrial fibrillation
ID band :placed on patient.
Abdomen soft and nontender,skin warm and dry.Cardiac rhythm:atrial fibrillation. No acute distress, no respiratory distress, respiration unlabored,expiratory wheezes in the left mid- lung posteriorly.
Two patient identifier checked.
Solumedrol 125mg diluted with IV fluid slow IVP via IV #1site left arm patent.IV site checked no pain,no redness ,#1 right antecubital space 20g angiocath,with aseptic technique, one attempt. Saline Lock flushed with 10ml saline. IV FLUIDS STARTED in Emergency department bag#1 – 1000ml NS.Rate wide open. Blood samples drawn:blood culture.
Rocephin 1gm mix in 10ml NS IVPB,IV PATENCY ESTABLISHED.
Tamiflu 75mg po.Confirmed right patient,medication, dose,time,and route. – Joselyn Whereisgod,RN.
0120AM :IV FLUIDS RATE CHANGED (Decreased to 100ml/hr.
Zithromax 500mg IVPB in 250ml(pre- mixed)over 1hour via pump.
0130AM:BP 129/80,Hr. 88,Respiration 20,02 Saturation 97% room air. Nohate,Michelle,RN.
Patient denies pain,calm and resting quietly.
Vital sign repeated Q30minutes . Patient remain stable.
Patient to be transferred to 4NorthEast.
Care transferred and report given to Winner,Emime,RN at 4NORTHEAST.
Patient Belongings done in Emergency department.MRSA Swab completed.Bed request completed.Transfer pending to floor.
IV FLUIDS STOPPED bag #1.Total amount infused = 500ml.IV converted to saline lock.Fall risk completed, no fall risk,denied pain 0/10.Patient report fax to floor. Patient is transported via Stretcher by Nursing staff with IV.
Admission condition: Stable.
Potassium serum 4.0
Chloride serum 108
Carbon dioxide 26
Creatine serum 1.03
Chest X- ray : Infiltrate in the right middle lobe.No fractures, Normal heart size.Mediastinum is normal.
Report: Great reporting by the medical team from EMS to the doctors and nurses.
Patient and family very pleased with the care so far.And will be transferred to 4NORTHEAST.
They demonstrated understanding.
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