AS, is a 74 year old male. He is married and has 3 children, and a few grand children. He lives in south bend with his wife and his youngest daughter. He seemed to be a family man. His family was in and out of the hospital while he was there. He is a very outspoken person; his family was very supportive.AS, formally worked for the city but is now retired. He is a full code with no known drug allergies. He presented to the emergency room with a fever of 100 degrees and complications from chemotherapy. Subjective symptoms upon admission were; nausea, vomiting and pain. Objective symptoms were a temperature of 100 degrees, and elevated blood pressure. He seemed calm, and was adjusting well with treatment and has accepted his medical condition. He has a past medical history of; Coronary artery disease (CAD), chronic renal insufficiency, myocardial infraction, and Gerd.
His present medicals conditions are; uro sepsis, hypertension, urinary retention, general weakness, aplastic anemia, gastrointestinal prophylaxis, deep vein thrombosis, osteoarthritis, and was recently diagnosed with neck and head metastatic cancer of unknown cause.
Surgical history include: Coronary artery bypass graft, cholecystectomy, gastric surgery, renal artery stenosis with stenting, port placement and right neck lymph node biopsy.
Assessment Data Sheet Patient Initials: AS Code Status full code Date of Care 9/4 and 5th. | Medical Diagnosis CAD, chronic renal insufficiency, uro sepsis , hypertension,General weakness, neck and head metastatic ccancer. Osteoarthritis. Allergies NKDA | Vital SignsB/P 177/101 on the 4th 130/72 on the 5th.Biox-98%Heart rate 74Respirations-20 (TPR, BP, & O, Sat) Pain (0-10 & describe)
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