[Solved]: Category Details Chief Complaint Confusion and…

Category Details Chief Complaint Confusion and change in mental state; obtained through the patient’s daughter History of Present Illness (HPI) 76-year-old woman, confusion and uncommunicative for 24 hours, fever, labored breathing, chronic bronchitis, limited mobility, and independent living Past Medical History (PMH) Coronary artery disease, hypercholesterolemia, hypertension, chronic bronchitis, COPD, osteoarthritis, epilepsy Family History (FH) Mother deceased (66, CHF); Father deceased (72, stroke) Social History (SH) Retired secretary/homemaker, assisted-living facility for 2 years, no alcohol, 1 pack/day cigarette use for 35 years, no illicit drug use Medications Amlodipine, Hydrochlorothiazide, Pravastatin, Valproic acid, Lamotrigine, Naproxen, Albuterol/ipratropium (Combivent) inhaler, Fluticasone propionate inhaler Allergies Sulfa (rash) Review of Systems (ROS) Unable to obtain due to patient’s condition Physical Exam Obese, elderly woman in respiratory distress. Warm, diaphoretic skin, tachycardia, fever, abnormal lung findings (rhonchi, dullness, diminished breath sounds) Vital Signs (VS) BP: 144/98, P: 100, RR: 29, T: 41°C, Wt: 154 lb, Ht: 5’5″ HEENT NC/AT, PERRLA, conjunctivae pink, no issues with ears, nose, teeth, tonsils, or pharynx Neck/Lymph Nodes Trachea midline, palpable thyroid, no nodes Chest Rhonchi bilaterally, dullness to percussion, diminished breath sounds in right lower lobe Cardiovascular (CV) Tachycardic, normal S1/S2, no heaves, thrills, or bruits Abdomen (Abd) Soft, non-distended, no masses, tenderness, or CVA tenderness Neurological (Neuro) Unresponsive to voice, withdrawal response to pain Labs – Na: 142 mEq/L, Hgb: 13.1 g/dL, WBC: 21.1 × 103/mm3, K: 4.3 mEq/L, Cl: 106 mEq/L, CO2: 23 mEq/L, BUN: 26 mg/dL, SCr: 1.8 mg/dL, Glu: 97 mg/dL. Hct: 39.5%, Neutros: 78%, Bands: 9%, Lymphs: 12%, Monos: 1%, RDW: 15%, RBC: 4.7 × 106/mm3, Plt: 155 × 103/mm3, MCV: 81.8 μm3, MCH: 27.1 pg. PT: 12.6 sec, aPTT: 29.1 sec, MCHC: 33.1 g/dL ABG pH: 7.50, pO2: 69 mm Hg, pCO2: 29 mm Hg, HCO3: 22 mEq/L, O2 saturation: 89% on FiO2 1 L via non-rebreather mask Chest X-Ray Infiltrate in right lower lobe, bilateral pleural effusions Assessment 1. Right lower lobe (RLL) pneumonia with increased work of breathing 2. Respiratory alkalosis secondary to pneumonia and tachypnea Plan 1. Induced sputum for respiratory secretion collection (Gram stain, culture, and sensitivity) 2. Collect two sets of blood cultures (anaerobic and aerobic) Questions: Create a list of this patient’s drug therapy problems.