1
Health History RUA
Chamberlain University
Nr 234- 61729
August 13, 2021
● Health History (Deanna)
Overview: Patient came to the ER with complaints of SOB on 7-4-2021, moved to Med-Surg on
7-5-2021. Released on 7-13-2021 with the PICC line.
, 2
V/S upon admission(7-4-2021): V/S : (7-4-2021)
900 hour 1100 hour
B/P: 107/64 B/P: 105/62
HR: 74 HR: 72
Temp: 98.3 Temp: 98.0
RR: 22 RR: 20
SpO2: 88% Sp02: 91%
Pt Name: C.S
Age/Sex: 66 years, Female
Reason for Visit: Dyspnea
Chief Complaint: SOB
weight: 240lbs/109.09kg
Height: 68 inches
Ethnicity: White
Allergies: Adhesive
Fall Risk: 12
Braden Scale: 17
SpO2: 3L/ml nasal cannula
Diagnosis: Acute hypoxemic Respiratory Failure
Diet: Clear Liquid Diet (Patient was scheduled for a PICC line, this is used for long term
antibiotics. Left Forearm)
Medications: Lantus (20 units), Prednisone (40 mg), Solu-Medrol, Losartan, Pantoprazole,
Guaifenesin (1200 mg), Spironolactone, Zosyn, Gabapentin, and Bumetanide(Bumex) 2mg daily
PO.
Past Medical History: Lung Cancer Radiation Treatment (2019), Malignant tumor of the lung,
Diabetes Mellitus, Coronary Arteriosclerosis, Aortic Valve Stenosis, Cardiac Pacemaker in situ,
Mixed hyperlipidemia
Current Medical History: Diabetes Mellitus, COPD, Benign Essential Hypertension,
Obstructive sleep apnea, acute on chronic diastolic heart failure, Atrial fibrillation,
History of present illness on Admission: Klebsiella (pneumonia), COPD, l
Left-sided heart failure with normal ejection fraction, Morbid Obesity, Type II Diabetes Mellitus
poorly controlled, GERD
Labs
Glucose at 9am: 123H (Type II DM)
Health History RUA
Chamberlain University
Nr 234- 61729
August 13, 2021
● Health History (Deanna)
Overview: Patient came to the ER with complaints of SOB on 7-4-2021, moved to Med-Surg on
7-5-2021. Released on 7-13-2021 with the PICC line.
, 2
V/S upon admission(7-4-2021): V/S : (7-4-2021)
900 hour 1100 hour
B/P: 107/64 B/P: 105/62
HR: 74 HR: 72
Temp: 98.3 Temp: 98.0
RR: 22 RR: 20
SpO2: 88% Sp02: 91%
Pt Name: C.S
Age/Sex: 66 years, Female
Reason for Visit: Dyspnea
Chief Complaint: SOB
weight: 240lbs/109.09kg
Height: 68 inches
Ethnicity: White
Allergies: Adhesive
Fall Risk: 12
Braden Scale: 17
SpO2: 3L/ml nasal cannula
Diagnosis: Acute hypoxemic Respiratory Failure
Diet: Clear Liquid Diet (Patient was scheduled for a PICC line, this is used for long term
antibiotics. Left Forearm)
Medications: Lantus (20 units), Prednisone (40 mg), Solu-Medrol, Losartan, Pantoprazole,
Guaifenesin (1200 mg), Spironolactone, Zosyn, Gabapentin, and Bumetanide(Bumex) 2mg daily
PO.
Past Medical History: Lung Cancer Radiation Treatment (2019), Malignant tumor of the lung,
Diabetes Mellitus, Coronary Arteriosclerosis, Aortic Valve Stenosis, Cardiac Pacemaker in situ,
Mixed hyperlipidemia
Current Medical History: Diabetes Mellitus, COPD, Benign Essential Hypertension,
Obstructive sleep apnea, acute on chronic diastolic heart failure, Atrial fibrillation,
History of present illness on Admission: Klebsiella (pneumonia), COPD, l
Left-sided heart failure with normal ejection fraction, Morbid Obesity, Type II Diabetes Mellitus
poorly controlled, GERD
Labs
Glucose at 9am: 123H (Type II DM)
