None
COPD, Hypertension, diabetes mellitus type 2
Appendectomy, cholecystectomy
40 pack year history (1 ppd x 40 years); social alcohol; no drugs; lives at home by himself, but children live in town and check on him periodically
| Time | Provider | Notes |
|---|---|---|
| 0830 | Tony Houseman, M.D. | Patient presented to the Emergency Department overnight via ambulance. They have been having difficulty breathing and feeling lightheaded. They had been sick with a productive cough for the last 4-5 days, worse from his usual baseline cough. The family reports the patient developed a fever 2 days ago that they treated with Tylenol at home. They were seen at an outpatient urgent care about 10 days ago for a COPD exacerbation. They were prescribed an inhaler and just finished a course of steroids. They initially responded to treatment but then worsened in the last few days. They continue to smoke 1 pack per day, They denies any chest pain, abdominal pain, back pain, extremity symptoms or headaches. He did feel dizzy earlier today, especially when standing. Continue to monitor. |
| Time | 0600 | 0800 |
|---|---|---|
| Heart Rate | 100 bpm | 110 bpm |
| Blood Pressure | 146/86 mmHg | 150/90 mmHg |
| Respiratory Rate | 28 breaths/min | 28 breaths/min |
| Pulse Ox | 90% | 88% |
| Oxygen in Liters | Room Air | Room Air |
| Temperature | 98.8 F | 98.7 F |
| Pain | 4/10 | 4/10 |