Date: September 26, 2050
The patient, Jean Harris, is a 65-year-old male admitted with acute respiratory distress secondary to pneumonia. He is currently on supplemental oxygen and requires continuous monitoring due to fluctuating oxygen saturation levels.
Jean Harris has a medical history significant for chronic obstructive pulmonary disease (COPD) and hypertension. He has been treated with bronchodilators and corticosteroids. A chest X-ray revealed bilateral infiltrates, confirming the diagnosis of pneumonia. His current medications include:
Medication | Dosage | Route |
---|---|---|
Albuterol | 2.5 mg | Inhalation |
Prednisone | 20 mg | Oral |
Amoxicillin | 500 mg | Oral |
Upon examination, Jean Harris appears to be in moderate respiratory distress. Vital signs are as follows:
Vital Sign | Value |
---|---|
Blood Pressure | 130/85 mmHg |
Heart Rate | 110 bpm |
Respiratory Rate | 24 breaths/min |
Oxygen Saturation | 88% on 4L O2 |
Auscultation of the lungs reveals diminished breath sounds bilaterally with wheezing. The patient's condition is stable but requires ongoing assessment and intervention.
It is recommended to:
Increase supplemental oxygen to 6L via nasal cannula to maintain oxygen saturation above 92%.
Administer a nebulized bronchodilator every four hours.
Reassess respiratory status every hour and consider an early consult with a pulmonologist if no improvement is noted.
For further inquiries or updates regarding Jean Harris's status, please contact Nurse [Your Name] at [Your Email] or call [Your Company Number].
Thank you for your attention to this matter.
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