Emergency Room Report.
Patient: Lodogod,Way James.
Age 83years.
Sex : Male.
Date: 12/29/2010
MR: Q0000999629.
TRIAGE:
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.
Allergy: NKDA
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.
MEDICATIONS:
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.
ALLERGY: NKDA
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.
DISPOSITION/DISCHARGE:
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.
LABORATORY:
NA 138
Potassium serum 4.0
Chloride serum 108
Carbon dioxide 26
BUN 20
Creatine serum 1.03
WBC 7.0
Hemoglobin 14.0
Hematocrit 39.4
Platelets 100.
Neutrophil 57
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 EDUCATION:
Patient and family very pleased with the care so far.And will be transferred to 4NORTHEAST.
They demonstrated understanding.
Nurses You Move Me 
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