“P.B. is a 64-year-old Caucasian male with a past medical history of heart attack, hypercholesteremia, and hypertension
“P.B. is a 64-year-old Caucasian male with a past medical history of heart attack, hypercholesteremia, and hypertension. He resides in the community of South Rockwood, MI. He presented with complaints of flu-like symptoms since 1/28. Patient was hypoxic in ER with an oxygen saturation of 83%, cyanotic, hypotensive, and tachycardic. Patient reports mostly body aches, chills, and diarrhea. Min expectoration. The chest X-ray was completed which reports patchy bilateral opacities. Patient reports recently being admitted back in September for multifocal pneumonia and bacteremia treated with a course of cefepimevancomycin. Symptoms include cough with some phlegm, fatigue, and malaise. Placed on nasal cannula. Discharged home on a 10-day course of Levaquin in which he states he was feeling good after. Admits to smoking cigars. Left leg swelling and history of deep vein thrombosis on Xarelto. The left leg is swollen, and the foot has purple-red blood clots. Denies prior home oxygen. Wheezing heard during respiratory assessment. Past surgical history of coronary angioplasty with stent placement and hernia repair. He has no advanced directives and declined to give any information. He is full code, and his wife is at bedside.” 5. Evaluate discharge planning goals or other long term planning goals
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