Labs were as follows:
WBC 22
Urine Culture- clear, no bacteria, no blood, no leukocytes
Lumbar puncture results- 1.2mMol/L, turbid, WBC 600mm3
CT results- revealed ventriculomegaly and sulcal effacement
Sara was admitted to the ICU with a diagnosis of bacterial meningitis. Her admission orders were as follows:
Gentamycin 2.5mg/kg IV q6hr
Rocephin 1g IV q4hr
Dilaudid 1mg IV q3h PRN pain
Zofran 4mg q2h IV prn nausea
Prophylactic Albuterol 2mg/Atrovent 250mcg breathing treatment q8hr while immobile
Diet- Regular as tolerated
CBC/BMP/CMP qAM
CT head without contrast qAM
Sara’s past medical history includes
Fractured wrist at age 14
Fractured clavicle at age 15
Sports induced asthma ProAir 90mcg 2puff q2hr PRN sob
DepoPrevera 150mg q 13 weeks IM
Mood dysregulation disorder Lithium 900mg daily PO
|
Student |
Date |
||||
|
Instructor |
Course |
||||
|
Patient Initial |
S.M. |
Unit/ Room# |
Med Surg 6 room 621 A |
DOB |
12/1/1950 |
|
Code Status |
Full Code |
Height/Weight |
6’1” 200lbs |
||
|
Allergies |
Penicillin, Ceftriaxone and Morphine |
||||
|
Temp (C/F Site) |
Pulse (Site) |
Respiration |
Pulse Ox (O2 Sat) |
Blood Pressure |
Pain Scale 1-10 |
|
102.3 Oral |
115 RA |
25 |
89% |
80/54 |
0/10 |
|
History of Present Illness including Admission Diagnosis & Chief Complaint (normal & abnormal) supported with Evidence Based Citations |
Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations |
|
Diagnosis: Sepsis, COPD exacerbation, Pneumonia Chief Complaint: S.M. states that over the course of the last week his CPAP machine at home has not been helping him while he sleeps. He reports increases SOB and increased difficulty breathing while sleeping. S.M. states that while he has been trying to sleep, he has had to use more pillows to prop him up as his CPAP machine isn’t working like it used to. S.M states that he has been coughing more and more and feels like he can’t get enough breath into his lungs, he feels like he has to gulp air more frequently. S.M states that at home his cough has gotten worse and he now has yellow phlegm that is coming up. S.M. states that he has had a fever for several days and he has been taking Tylenol around the clock to try and bring the fever down. Prior to coming into the ER S.M. states that he was getting more and more dizzy and weak and when he couldn’t stand up to use the restroom upon waking up this morning, he finally called 911. Rationale: COPD is what_____________________ (citation) People with COPD are more susceptible to pneumonia because _______________(citation). Pneumonia can contribute to a sepsis diagnosis how __________ (citation). Sepsis does what to the body _____ (citation) |
Neuro:
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