Medical Record For Barney Hodges

Patient Information

Name
Barney Hodges
DOB:
5/01/1955
MRN:
140108
Admitting Diagnosis:
Pneumonia
Admitting Physician:
Michael Stark, M.D.

Past Medical History

Allergies

Amoxicillin

Medical Problems

Hypertension, CAD, asthma, cervical herniated disc

Surgical History

Tracheostomy 2021, cervical fusion surgery 2021

Provider Notes

Time Provider Notes
0830 Michael Stark, M.D. Admitted to the hospital a week ago from LTACH with thick green-yellow secretions noted with trach suctioning. Patient with fever of Temperature 103.5.
Patient stable after week-long course of antibiotics. Patient has clear to white secretions from trach and requires suctioning every 4 to 6 hours.

Vital Signs

Time 0400 0800
Heart Rate 84 96
Blood Pressure 128/76 140/90
Respiratory Rate 22 24
Pulse Ox 98% 94%
Temperature 99.2 99.4