Cambridge College of Healthcare & Technology
Patient: D.Z. Attending Physician:
S Age: 68 Dr.D
Situation Gender: Male Patient Chief Complaint:
Height/Weight: Acute exacerbation of COPD
Allergies: NKA
Time: 1600
Past Medical History: Hypertension, Current Medications:
B Diabetes Type 2, pneumonia yearly for theEnalapril (Vasotec)
Background past 3 years Hydrochlorothiazide (HCTZ)
Social History: Metformin (Glucophage)
2 pack a day smoker for the 38 years Fluticasone/salmeterol (Advair)
Vital Signs: Falls Risk: Yes _x__ No______
A
Assessment BP 162/84 HR 124 RR 36 Temp 102 Accucheck:
SPO2 88% Pain Yes ___X_____No _______
IV Site:
Yes __X___ No___________
Isolation: -------------- IV of D5W at 50 ml/hr
Respiratory: ---------- Difficulty breathing at rest, cough is IV Fluid:
productive of thick yellow green sputum Yes ___x_____ No________
Decreased breath sounds, expiratory
wheezes and coarse crackles in both lower
Oxygen:
lobes anteriorly and posteriorly Yes __x_____ No _________
Cardiovascular: ------
Neurological: -------- Irritable and anxious
GI/GU/I & O: ---------
Integumentary: ------
Psychological -------- Cachectic
Patient: D.Z. Attending Physician:
S Age: 68 Dr.D
Situation Gender: Male Patient Chief Complaint:
Height/Weight: Acute exacerbation of COPD
Allergies: NKA
Time: 1600
Past Medical History: Hypertension, Current Medications:
B Diabetes Type 2, pneumonia yearly for theEnalapril (Vasotec)
Background past 3 years Hydrochlorothiazide (HCTZ)
Social History: Metformin (Glucophage)
2 pack a day smoker for the 38 years Fluticasone/salmeterol (Advair)
Vital Signs: Falls Risk: Yes _x__ No______
A
Assessment BP 162/84 HR 124 RR 36 Temp 102 Accucheck:
SPO2 88% Pain Yes ___X_____No _______
IV Site:
Yes __X___ No___________
Isolation: -------------- IV of D5W at 50 ml/hr
Respiratory: ---------- Difficulty breathing at rest, cough is IV Fluid:
productive of thick yellow green sputum Yes ___x_____ No________
Decreased breath sounds, expiratory
wheezes and coarse crackles in both lower
Oxygen:
lobes anteriorly and posteriorly Yes __x_____ No _________
Cardiovascular: ------
Neurological: -------- Irritable and anxious
GI/GU/I & O: ---------
Integumentary: ------
Psychological -------- Cachectic
