NURSING PAPER
CHIEF COMPLAINT: FEVER AND PROBLEMS BREATHING
HISTORY OF PRESENT ILLNESS
This is a 67 year old female with history of right MCA territory infarct with resultant left hemiparesis and aphasia, Type 2 diabetes mellitus, hyperlipidemia and anemia, who was sent over from Senet Care Nursing Home to Global Hospital for a temperature of 100.5 degrees and hypoxia of 85%.
PAST MEDICAL HISTORY
--RIGHT TERRITORY CVA WITH LEFT HEMIPARESIS AND APHASIS
--HYPERTENSION
--TYPE 2 DIABETES MELLITUS
--HYPERLIPIDEMIA
FAMILY MEDICAL HISTORY
--CABG
--CORONARY ARTERY DISEASE
--CANCER
SOCIAL HISTORY
--no alcohol, drugs or illicit drug use
PATIENT MEDICATIONS AND ALLERGIES
--FAMOTIDINE
--LANTUS SOLUTION
--SPIRONOLACTENE
--GABAPENTIN SOLUTION 250 MG/5ML
--IPRATROPUM-ALBUTEROL SOLUTION
--ASPIRIN TAB
ALLERGIES
PENICILLIN
PATIENT PHYSICAL EXAM
--NONE
PATIENT LABS/DIAGONOSTIC TEST RESULTS
--ABNORNAL RBC
--ABNORMAL HEMOGLOBIN
--ABNORMAL PLATELET COUNT