Patient Information: Name: Sarah Adams Age: 65 Gender Female Past Medical History: Hypertension, CAD
Patient Information: Name: Sarah Adams Age: 65 Gender Female Past Medical History: Hypertension, CAD, Type 2 Diabetes, Chronic Obstructive Pulmonary Disease (COPD), Smoker 1ppd x’s 25 years, Past Surgical History: Cholecystectomy in 2022. Current Medications: Losartan 50 mg PO everyday Glimepiride 2 mg PO daily Spiriva 18mcg inhalation daily Albuterol 100mcg 1-2 puffs prn SOB Presenting Complaint: Sarah Adams is a 65-year-old female admitted to the medical-surgical unit with fever, shortness of breath and altered mental status. She has a h/o COPD and has been experiencing worsening dyspnea for the past week. Patient Adams’ initial presentation is as follows: confusion, tachypnea, accessory muscle use, bilateral coarse crackles. Orders Place large bore IV x’s 2 Normal Saline 0.9% 30mL/kg then NS 125 mL/hr Azithromycin 500 mg IV daily Ceftriaxone 1gm IV every 6 hours Oxygen 2-6L to keep O2 sats 90-92% Activity: Up to chair three times a day Diet: ADA diet Labs: CBC, CMP daily, ABG x’s 1
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