Age/Sex : 79years old man.

Status :Impatient Admission.

Attending Doctor: Don’thate,Big.

Medical record number: Q555500512.

Account number:Q000000071

Department: MedTelemetry.

No family members at his bedside.

Son: Lam Longboy. 999-999-0000

Confused, AMS.

Limitation of treatment.

Aspiration Pneumonia, Encephalopathy, Leukocytosis,AKI,Hypernatremia.

Hypoxic,Respiratory failure.

No distress,quiet, denied pain 0/10.

Round the Clock Respiratory therapists treatment.

Lasix 20mg ivp Q8hours.

Zosyn 3.375gm IV Q8hrs.

Saline lock left forearm.

Morphine sulfate 2mg IV Q2hours .

Assessment of pain 0/10.

Reassessment of pain level 0/10.

Laboratory Studies.

WBC =13.0.

H/H 9.3/31% .

Bun 22,Cr=2.0.

NA =144.


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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