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