Patient Information I collected on a clinical day

Patient Information I collected on a clinical day

Please use below information to assist with assignment.

Client is an 87 yrs old male

Diagnosis: Pulmonary Thromboembolism

Last Wt: 84.7 kg (186 lbs 11.7 oz)

Code Status: NCB (No code blue)

Vitals: T-96.3, P-86, R-18, BP-108/55, and 02 sats 92 % on room air.

Medications Presently taking

1. Amoxicillin-pot Clavulanate 875 mg BID orally

2. Carbamazepine (Tegretol x R) 200 mg TID orally

3. Enoxaparin (Levenox) 1 mg/kg subcutaneous Q12H

4. Furosemide (Lasix) 10 mg/ml 60 mg IV BID

5. Lisinopril (Zestril, Prinivil) 2.5 mg daily orally

6. Potassium Chloride (klor-con) 20 mEq BID orally with meals

7. Gabapentin 100-200 mg BID orally. 100 mg (1 cap) at 11 am and 200 mg (2 caps) at 5 pm.

8. Quetiapine (Seroquel) tab 25 mg orally at night.

9. Spironolactone (Aldactone) 12.5mg daily by mouth

10. Tamsulosin (Flomax) 24 hours capsule 0.4 mg daily by mouth

On admission x-ray did confirm substantial pleural effusion on the left side. This may be contributing to his symptoms of shortness of breath, fatigue and low blood pressure. There were also presence of pulmonary emboli and possible pneumonia, he was admitted for further management of these issues.

Patient is generally oriented to person and place though not time. He has periods of confusion and difficulty with memory.

Plan: patient will be discharge to skilled nursing facility once medically stable but OT and PT continue to see him 1-2 times a day during his remaining inpatient stay.

OT- continue to see patient 1-2 times a day to assist with selfcare management training.

PT- see patient 1-2 times per day working on increasing his exercise tolerance and independent with transfers while maintaining oxygen saturation greater than 90.