sion (29/09/04) by her GP, and sent to the hospital. She has a history of arrhythmia, AF, left side stroke, eye and hand problems, heading to renal insufficiency, and Congestive Cardiac Failure (CCF). The patient reports she has no allergies.
O2 was applied initially using a 15L non-rebreather mask. The patient was nebulized with Ventolin/Atrovent, and later a Hudson mask at 6L of O2 was used.
Lanoxin (Digoxin) 250 ug one/day
Coumadin 2 mg as directed
Patient is awake, but weak, SOB, increase of breathing rate, dry skin,
head - no sign of URTI, no swollen glandular, throat not red, ----- no jaundice, no head injury, swollen jugular veins, wheezing bilaterally.
BP 180/110, Pulse 90/min, O2 Sat. 90%, Temp. 38.1
Auscultation showed increase of breathing rate. ------- everywhere, after neb -----------of airway exit. Pneumonia?,
1. Blood, FBC, EUC, digoxin, blood culture, coagl, and INR, add on LFT, Ca
Full vitals were taken and monitored every 30 minutes. The patient was placed on a cardiac monitor and a 12 lead ECG attended. An IV cannula, 18 gauge, was placed in the left arm, bloods were drawn. IV fluids were given. Panadol syrup given. Fluid intake/output was monitored
Arterial blood gases (ABG) showed a reduced P02 of 56 mmHG and reduced O2 saturation (89.3%).
The chest xray showed scattered consolidation in both lungs. There was heavy consolidation in the base of the lower lobes.
The patient complained of shortness of breath (SOB) with a respiration rate (RR) of 44 on initial presentation. She was febrile, with a temperature of 38.1. Coarse crepes were heard on auscultation. The patient had a cardiac history of CCF and Chronic Atrial Flutter (AF).
She had a history of an old (> than 2 years) Cerebral Vascular Accident (CVA) resulting in moderate left-sided hemiplegia.
The patient lives at her daughter's home (relies on daughter for most Activities ...