Patient Name:  Birdy Well

Patient ID: 3487132

Admission Date: 4/12/xx

DOB: 02/20/XX

Chief Complaint: Pneumonia

History of Present Illness: Birdy Well is a 86yr old who was transported from the Nursing Home to the ER via ambulance with slight confusion, dyspnea, and productive cough.  

 

Medical History:  COPD, HTN, Emphysema

Medications: atrovent, decadron, theophyline, lopressor

Allergies: Morphine


Social History: She does not drink, she quit smoking 10 years ago

Family History: Widow, with 2 children 

Physical Examination:

General:  This is a female who has slight confusion, Ht: 65 in Wt: 70 kg

Vital Signs: Blood Pressure 160/90, heart rate 90, Respiration 28, Temperature 101.2°F

HEENT: Clear

Lymph: Unremarkable

Neck: No goiter, no jugular venous distention

Chest: Crackles bilaterally

Heart: Regular rate and rhythm, no murmur, rub or gallop

Abdomen: Soft and tender

Genitourinary: tender

Rectal: Unremarkable.                                  

Skin: pale, moist mucous membranes. Skin turgor within normal limits.

Laboratory and X-ray Data: sodium 137, Potassium 4.6, glucose 123, BUN 33, creatinine 0.9, white count 14600, Hemoglobin 13.1, Hematocrit 41.3, platelets 483. 

 

Impression:

  1. Pneumonia
  2. COPD Exacerbation

Plan:

  1. Admit to Med-Surg
  2. Start antibiotic therapy
Last modified: Tuesday, March 31, 2020, 5:51 PM