Visit Type: Acute

Established Patient

Place of Service: Nursing Facility

CC: Pneumonia/Respiratory failure with hypoxia

HPI: 85 year old female with NPO/g tube presented today with a temp 101.0; Heart Rate 74; Respiratory Rate 27; Hx of COPD, CHF, and pneumonia. CXR shows right upper lobe pneumonia, CBC/BMP results remain pending. Started on Prednisone 40mg daily x 5 days, Azithromycin 500mg x1 then 250mg x4 days, added Rocephin 1gm IM x5 days. She continues on Duo Nebs q 4hrs; Proventil q 4hrs prn. MOLST; DNR/DNI/send to hospital Family notified, they plan on coming to see resident tomorrow AM.

Risk Level: Yellow

ROS:

Pain Assessment Completed: non-verbal

Does not appear to be in pain: Yes

Cognitive impairment: Yes

Cognitive Impairment type: Dementia

Diabetic Testing: N/A

Additional Notes: ROS unobtainable due to dementia

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