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.
Nurses You Move Me 