435 CASE SCENARIO. COUGHING OUT BLOOD?.R/O TUBERCULOSIS.

Patient name: Timbuktu, Neverme.

Attending Doctor: Y’knowme,Benson.

Inpatient admission. Date of admission 05/01/0000

33years old male coughing out blood for two days,night sweats. Brought in by ambulance.

Primary diagnosis: Coughing up blood ×2 days (Hemoptysis)R/O TB.

Secondary diagnosis:No Medical History. Isolation Precautions:Airborne. Sweating, showered twice today.

TB infection G.expert positive. AFB culture.1-2-3,first AFB(-)(AFB in am x 2 )Ambulatory ,saline lock left ac 20guage,patent/clean/dry.

Advanced Directive : No. Copy on the chart. K=3.8,Na=140,Wbc =5.0,H/H=11.6/34.6.Allergy NKDA.

Diet :Regular diet.

Room air ,full code.

Next of king:Timbuktu, Yeye.

Phone: 999-99-9999

plan:

Discharge home in 2 to 3days once cleared by San Bernadino County.

Please follow doctor orders and your facility policy and procedures.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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