A.R. is a 31-year-old male, who was brought into the ER via ambulance, after his Leave a reply A.R. is a 31-year-old male, who was brought into the ER via ambulance, after his partner called 911 when he blacked out and collapsed. Per his partner, He has been fighting a cold for the last few days and has not been breathing really well. Patient is now awake and alert but is currently unable to stand due to dizziness & fatigue, crackles in the lungs are heard. ?Admitting Diagnosis: Community acquired Pneumonia, Dehydration ?Patient medical history as follows: HTN, hyperlipidemia, depression, hypothyroidismPatient surgical history as follows: Cholecystectomy 1999.H: 56W: 230 Lbs.FULL CODEAllergies: SulfaVital signs as follows:BP: 84/56 mmHgHR: 116RR: 24Temp: 101.8Oxygen Saturation: 88% on room airLabs as follows:WBC: 23,000Sodium: 139Potassium: 5.2Hgb 16/ Hct 50Bun 35, Creatinine 1.32Orders as follows:Oxygen 2L via nasal cannula (Titrate to keep sats > 95%)0.9% Sodium Chloride 1000ml bolus x 1 followed by 0.9% Sodium Chloride 100 ml/hr continuously via peripheral IV.Cefuroxime 1gm IV q 24 hrsVancomycin 1 gm IV q 12 hrsTylenol 650 mg PO q6 hours PRN mild pain or fever > 100.5Ipratropium Bromide 0.02% via HHN q 4 hrs PRN shortness of breath or wheezingCymbalta 20mg PO q dayMetoprolol 25mg PO BIDZocor 20mg PO q HSLevothyroxine 137mcg PO q AMPantoprazole 40mg EC DR PO q AC lunchVS q4hrs with Orthostatic blood pressures Q8 hoursChest x-rayEKGRegular dietActivity as toleratedFall precautionsInitiate cardiac tele monitoring? Labs on the next round:CBCBMPDimerLactic AcidHgA1cTroponin q 8hrs x 3Blood Cultures x 2 setsDuplex of Bilateral Lower ExtremitiesViral Respiratory PanelSputum Culture & SensitivityUA & Culture This entry was posted in Nursing on December 6, 2021 by .
