541 CASE SCENARIO: PNEUMONIA. CHIEF COMPLAINT DIFFICULTY WITH RESPIRATION.

Patient had fever and productive cough with greenish Sputum for 1week.Coughing ×1 week,Shortness of breath x2days,labored breathing.Symptom worsen so he went to primary care physician.He advised patient to go to emergency room immediately.

KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000.INTERDISCIPLINARY KARDEX. Age/Sex 25years old man.

Account number Q005634372.

MR #Q00058867544.

Admission date 09/21/2021@08am.

Admission status: Inpatient admit.

Location MedTelemetry.

Room 42114.

Attending doctor Tommy Holbib.

Patient name: Redpot Michaelsin.

Resuscitation Status :Full code.

Primary diagnosis Pneumonia. Chief complaint: Difficulty with respiration. Secondary diagnosis: None.

No known home medication.

Isolation Status : Standard Precautions.

Fall risk: No.

Suicidal risk: No.

Skin intergrity impaired: No.

02 at 2liter NC.

Allergy:NKDA.

Weight 185lbs.

Height: 5feet 6inches.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet Cardiac heart health diet.

Medications:

Zofran 4mg IV Q4hours prn Nausea/Vomiting .0.9NS @ 100ml/hour,left forearm 20guage clean/ dry/ intact.

Albuterol sulfate 3ml Amp.per respiratory therapist.

Toradol 30mg IV Q6hour prn severe pain. Tylenol 500mg po Q4hours prn temperature. Cefazolin 1gm IV Q8hours.

Rocephin 1gm IV Q24hours.

Azithromax 250mg po Q12hours.

Benadryl 25mg po Q4hours prn itching. Laboratory results:

WBC 13.6.

H/H 12.0,37.2.

Magnesium: 1.8.

MCV: 88.5.

MCH: 29.0

MCHC: 33.0.

Platelet 378.

Na 135.

K: 3.4.

Cl: 98

.Ca+= 8.8.

Glucose:99.

Cloudy yellow urine.

Leukocytes in urine.

Discharge plans: Discharge home to family in two if there is no temperature for 24hours.

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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