526 CASE SCENARIO: PNEUMONIA.

Pneumonia is the infection that inflames the lungs. 🫁It can be one lung or both lungs with fluid or pus.It could be mild or severe. Signs and Symptoms are difficulty with breathing ( sob),Coughing with phlegm,fever,Chills. It could be mass,covid or something else go to the emergency room or call your doctor.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 38years Female.

Account number : Q006543237.

MR # : Q00058867522.

Admission date : June 10th 2021@04am.

Status: Inpatient admission.

Location: MedTelemetry.

Room : 42111.

Attending doctor: Greener Insent.

Patient Name: Mengala ,Beauty .

Resuscitation Status: Full code.

Weight 165lbs.

Height 5feet 6inches.

Primary diagnosis : Pneumonia. ( Community Acquired Pneumonia with right lobe infiltration)

Secondary diagnosis:Fever,Coughing, Pain right breast,generalized body ache.(+) Amphetamine, (+) Cannabinoids.

Risk for fall: No.

Suicidal risk: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart. Isolation Status: Standard Precautions.

Diet: Cardiac heart health diet.

Allergy: Pencillin.( Gives me rash all over my chest and back)

02 @ 2liter NC.

Transportation method : Wheelchair.

Doctor orders:

CT scan of the chest to r/o Embolism.

Chest Xray.

Duoneb treatment by Respiratory therapist Q6hours.

D Dimer elevated.>250ng/ML

Urine analysis.

Laboratory tests CBC with differential, Comprehensive Metabolic panel, Coags,ESR in am .

Ambulate to the hallway TID. 0.9NS @75ml/hour IV right forearm 18guage. Clean/ Patent/Dry.

Levaquin 750mg IV Q24hours.

Flagyl 500mg IV Q8hours.

Lovenox 40mg SubQ Q24hours.

Motrin 400mg po Q6hours mild prn pain. Norco 10/325mg 1tablet po Q4hours prn moderate to severe pain.

Zofran 4mg IV Q4hours prn nausea/Vomiting. Laboratory results:

WBC 8.5.

H/H 12.0,38.2 .

K:3.7.(replaced with 20meqkcl po)

Na : 138.

Magnesium: 1.7.( replaced with 2gram of magnesium IV)

Calcium 10.7 Ultrasound of right breast ordered by the doctor. ( right breast mass and pain)

Plan:Discharge home when medically stable with family in two days.

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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