Mr. David Williamson a 78 year old

Mr. David Williamson a 78 year old male African American, single and lives alone, and is currently admitted with a medical diagnosis of COPD and Pneumonia. Addresses client centered concepts related to alcohol withdrawal, respiratory status, and allergic reactions. On this admission, patient also presents with chief complaints of difficulty of breathing, and frequent productive cough for about the past two hours today. Denies chills, increasing chest tightness, and nocturnal symptoms. Has a medical history of Asthma, COPD, smoke cigarette one pack a day. hypertension, and hyperlipidemia. Patient illicits alcohol used but denies drugs used. Current medications: Oxygen 2 liter via nasal cannula Albuterol 0.083 % via nebulizer 4 X day as needed (PRN) Proventil MDI (inhaler) two puffs two times a day as needed (PRN), Theophylline 500 milligrams oral two times a day (BID), Hydrochlorothiazide (HCTZ) 25 milligrams oral daily Lorazepam (Ativan) 2 mg 1 tab oral 2 X day as needed Folic acid 1 mg oral daily Lipitor 40 milligrams oral daily at bed time. Physical assessment findings: Mr. DW appears anxious, moderately dypsneic at rest. Color palor – abnormal for ethnicity Vital signs (V/S) B/P 130/80, HR. 110, R. 22. oxygen oxymetry: 88 % ABG: PC02 55, PAO2 88%, PH 7.30 Weight: 170 Lbs, height: 5.4 Labs: On admission Peak Flow Rate (PFR) 60% which indicates mild dyspnea and wheezing. CBC: Hemoglobin 16 and Hematocrit 45 (H/H) 16/49, WBC: 15,000. Blood Alcohol Level 2.0 Review of system information (ROS): Neurological: Alert and oriented to time, place, and person. Good historian Respiratory: Dyspnea , tachypnea Breath sounds: Wheezing inspiratoty and expiratory, and on auscultation Adventitious sounds: Rales and crackles findings to bilateral lower lobes Cardiovascular: Heart rate 110 strong and regular Jugular venous distention: Negative on assessment Peripheral edema 2 + Abdomen: Abdomen soft, non distended Elimination Pattern Gastro intestinal (GI): Bowel sounds present in all four quadrants Bowel habits: Consistent. Last BM: 1/13/202022: Stools characteristics: Firm Genitourinary (GU): As per patient states, no abnormality upon urination. Void frequently, color: Clear yellow urine Mobility: Mobile with steady gait Integumentary (skin): Dry, warm, and intact Skin color: Fair. pallor noted Diet: 2 grams sodium as ordered Oral fluids: No restrictions Image transcription text Patient Initials – Clinic Date: -/ Date of Birth: -/-/- Allergdes: Advance Directives: HCP/DNR/DNI Patient Diagnosis Cultural: chief Complaint Vital Signs Support System – Lives In Ant -House -SNF-Adutt Home = PMH Review of Syste… Show more

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