Account number :Q005634332.

MR #Q00058867546.

Admission date: 06/12/2021@0730am.

Status: Inpatient admission.

Location: MedTelemetry ♥

Room #42116.

Attending doctor :Owomi Kende.

Patient name: Blessing Promises.

Resuscitation Status :Full code.

Primary diagnosis: Respiratory Failure. Intubated due to respiratory failure. Left chest shows large mass in the lungs 🫁Chest tube inserted immediately. Concern about possible Empyema.Immediate consultation: Pulmonology consult doctor Peperstew,Showme.

Infection disease consult doctor :Cutest, Mike.

Cardiothoracic consult: doctor Leio,Vegase.

06/21/2021 Emergency bronchoscopy at bedside.

06/22/2021 @ 0730am Extubated.

02 at 4liters NC.

Alert and oriented x3.

06/24/2021 left VAT done.

Remain in ICU for two days due to desaturation and later transferred to MedTelemetry.

Bedside bronchoscopy done to remove secretions in the left lungs.

Mild pneumothorax but stable, right chest tube discontinued continue to monitor patient.

Secondary diagnosis : Hypertension COPD Exacerbation, difficulty to swallow, sore throat, weakness,mild dry cough.

Weight : 135lbs.

Height: 5feet 3inches.

Allergy: NKDA.

Isolation Status: Standard Precautions.

Risk for fall: No.

Suicidal risk: No.

Do patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet :Regular diet.

Bedside commode.

Chest tube left side with Sersanganous Drainage,mild airleak doctor made aware,mild crackles.

Laboratory results:

WBC: 8.5.

H/H 7.9.0,22.2.( received 1unit of PRBC)

Magnesium level 1.7 .(replaced with 2gm of magnesium)

Na :124 .Replaced.On 3% Nacl(Sodium chloride) for hyponatremia.

K level :3.5 replaced with 20meqkcl ×1.

Laboratory test :

CBC with differential and Chem 7 at 05am.

Doctor orders:

Continue chest tube to suction,continue to monitor patient frequently.

Chest Xray in am.Swallow evaluation. Zosyn IV Q8hours.

Clindamycin 900mg IV Q8hours.

Carvedilo 6.25mg po Bid scheduled .

Accucheck Qac and Qhs.Sliding scales.

Dilaudid 0.5mg IV Q3hours prn severe pain. Zofran 4mg IV Q4hours prn nausea/ Vomiting. Norco 1tablet po Q4hours prn moderate pain. Tylenol 500mg po Q4hours prn temperature. 0.9NS @50ml/hour right forearm 18guage clean dry and intact.

Respiratory therapist Q6hours for breathing treatment + prn.

Transportation method: Wheelchair.

Discharge plans: Patient will be discharged when medically stable and no drainage from chest tube.

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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