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Skin Excoriated, otherwise normal Neuro Slightly altered, but baseline Radiologic Exam: Radiology Chest X-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia. Labs: Na: 141 Creatinine: 1.6 K: 4.2 WBC: 19.6 Cl: 98 Hgb: 10.8 Bicarb: 23 Hct: 36.2 BUN: 24 Platelets: 115 Micro Blood Culture No growth at 48 hrs Sputum Culture Gram Stain: 4+ squamous epithelial cells, 4+ segmented neutrophils, no organisms Culture: No growth at 48 hours Pneumococcal Urinary Antigen Positive Legionella Urinary Antigen Negative Problem Assessment Cues Nursing Dlagnosis Subjective Cues: Objective Cues:

Skin Excoriated, otherwise normal Neuro Slightly altered, but baseline Radiologic Exam: Radiology Chest X-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia. Labs: Na: 141 Creatinine: 1.6 K: 4.2 WBC: 19.6 Cl: 98 Hgb: 10.8 Bicarb: 23 Hct: 36.2 BUN: 24 Platelets: 115 Micro Blood Culture No growth at 48 hrs Sputum Culture Gram Stain: 4+ squamous epithelial cells, 4+ segmented neutrophils, no organisms Culture: No growth at 48 hours Pneumococcal Urinary Antigen Positive Legionella Urinary Antigen Negative Problem Assessment Cues Nursing Dlagnosis Subjective Cues: Objective Cues:

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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Name: Haesoo Age: 69 years old Sex: Female Chief Complaints: dyspnea and cough for 1 week Admitting Diagnosis: HCAP (Healthcare associated Pneumonia) Medical Hx: Dyslipidemia Alcoholic cirrhosis Hypertension Medications maintained: Lisinopril Atorvastatin Tiotropium Fluticasone/salmeterol Albuterol inhaler Vitals Signs Temp. 38.4 C HR: 89 bpm RR: 18 bpm BP: 140/86 02 Sat: 84% room air; 98% nasal cannula Physical Exam General Elderly female, looks older than stated age HEENT Mildly icteric, pupils equally round and reactive to light and accommodation Neck Supple Resp Coarse breath sounds, rhonchi and wheezes heard throughout Card Regular rate and rhythm, no murmurs, rubs, or gallops Abd Slightly distended Ext No edema
Transcribed Image Text:Name: Haesoo Age: 69 years old Sex: Female Chief Complaints: dyspnea and cough for 1 week Admitting Diagnosis: HCAP (Healthcare associated Pneumonia) Medical Hx: Dyslipidemia Alcoholic cirrhosis Hypertension Medications maintained: Lisinopril Atorvastatin Tiotropium Fluticasone/salmeterol Albuterol inhaler Vitals Signs Temp. 38.4 C HR: 89 bpm RR: 18 bpm BP: 140/86 02 Sat: 84% room air; 98% nasal cannula Physical Exam General Elderly female, looks older than stated age HEENT Mildly icteric, pupils equally round and reactive to light and accommodation Neck Supple Resp Coarse breath sounds, rhonchi and wheezes heard throughout Card Regular rate and rhythm, no murmurs, rubs, or gallops Abd Slightly distended Ext No edema
Skin Excoriated, otherwise normal Neuro Slightly altered, but baseline Radiologic Exam: Radiology Chest X-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia. Labs: Na: 141 Creatinine: 1.6 K: 4.2 WBC: 19.6 Cl: 98 Hgb: 10.8 Bicarb: 23 Hct: 36.2 BUN: 24 Platelets: 115 Micro Blood Culture No growth at 48 hrs Gram Stain: 4+ squamous epithelial cells, 4+ segmented neutrophils, no organisms Culture: No growth at 48 hours Sputum Culture Pneumococcal Urinary Antigen Positive Legionella Urinary Antigen Negative Problem Assessment Cues Nursing Dlagnosis Subjective Cues: Objective Cues:
Transcribed Image Text:Skin Excoriated, otherwise normal Neuro Slightly altered, but baseline Radiologic Exam: Radiology Chest X-ray showed focal consolidation in the right lower lobe, suggestive of pneumonia. Labs: Na: 141 Creatinine: 1.6 K: 4.2 WBC: 19.6 Cl: 98 Hgb: 10.8 Bicarb: 23 Hct: 36.2 BUN: 24 Platelets: 115 Micro Blood Culture No growth at 48 hrs Gram Stain: 4+ squamous epithelial cells, 4+ segmented neutrophils, no organisms Culture: No growth at 48 hours Sputum Culture Pneumococcal Urinary Antigen Positive Legionella Urinary Antigen Negative Problem Assessment Cues Nursing Dlagnosis Subjective Cues: Objective Cues:
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