Patient History and Assessment
D.E. is a 59 year old Caucasian male who was admitted to the Northridge Hospital Emergency Room on the 21st of February by paramedics after they responded to a 911 emergency call by the patient’s wife. D.E. was experiencing SOB, dyspnea and alternating levels of consciousness upon arrival of the response team. Oxygen was applied via nasal cannula and the patient was transported to the ED. D.E. did not complain of any chest pain or nausea and vomiting. Just stated he woke up during the night while he was experiencing a coughing attack resulting in his feeling unable to breathe. In the ED a chest X-ray was performed confirming a diagnosis of Pneumonia as white patches were evident bilaterally.
D.E. has a reported allergy to Morphine which results in uncontrolled emesis. He also stated he has an allergy to green bell peppers which also cause him to vomit. His past history includes diabetes mellitus, chronic back pain, hypercholesterolemia, hypertension, depression and insomnia. Past surgical procedures include bulging disk repair, and cholecystectomy.
The patient has managed his Diabetes at home by taking Glyburide 5mg PO twice a day along with 1000mg of Metformin. Benazepril 20mg is taken to manage HTN. He takes Methocarbamol one tablet PO four times a day to manage muscle spasms related to his chronic back pain, and has a concomitant PRN of Hydrocodone/Acetaminophen 10/325mg PO every four to six hours. To control his high cholesterol Lovastatin 20mg PO daily is taken. Recently, the patient was started on 100mg PO of Gabapentin to help with insomnia. He currently takes 75mg Nortriptyline to manage depression.
Patient’s family history include a father who passed away at 67 years-old of a myocardial infarction, and a mother, per patient’s statement, who is “In better shape than I am!”
Patient’s vital signs at time of care were blood pressure 159/81, Temperature 97.8 –oral, pulse 87, Respirations 18 per minute, Oxygen saturation 95% on intermittent 2L per soft mask. (Patient only applies O2 when he feels out of breath despite instruction). Patient reported no pain on a pain scale of 0 to 10.
Patient’s bed was lowered and in locked position. Tripping hazards were removed and pathway is clear to the bathroom. He prefers to keep his hat and his shoes on in bed. Face is symmetrical. Pupils are equally round and reactive to light and accommodation. He is alert and oriented to person, place, time, and situation. Skin is intact with some small scratches from his household cats on his ankles and forearms. Skin is warm and dry. Currently running 100ml an hour of Normal Saline through a #20 gauge needle inserted in his right forearm. IV site shows no signs of infection or infiltration. Grips are equal and strong. Pulses are equal and strong. Full range of motion in all extremities, ambulatory. Neck veins are flat, normal S1 and S2. Wheezes and rhonchi present bilaterally, respiration rate within normal range. Abdomen is soft and non-distended with positive bowel sounds in all four quadrants. Had a “large, healthy” bowel movement yesterday. Urine is cloudy and yellow with an output of 800mL after a total intake of 1100mL.
EKG was negative for ischemia and showed normal S1 and S2 with no murmurs, or S3, S4 sounds.
D.E. is on a cardiac diet due to hypertension. Is able to feed himself and has no swallowing deficits.
D.E. was born and raised locally in Southern California. He is currently living in Reseda with his wife and five cats. He identifies with white American culture. D.E. completed high school here in southern California and then became a tour bus driver and drove all over the United States for nearly thirty years. Eventually, he had to take an early retirement due to chronic back pain associated with constant driving and the heavy lifting of suitcases on and off the bus. He had undergone surgery to repair a bulging disk in his lower back which...
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