Day 1 – E.R.
BP: 100/58
HR: 120
O2: 78%
Temp: 102.4
Resp: 9
WBC: 18.0
Bands: 14%
HgB: 14
HCT: 50%
PLT: 350
Glucose: 250 mg/dL
BUN: 20 mg/dL
Cr: 2.4 mg/dL
pH: 7.30
PaCO2: 68 mmHg
PaO2: 45 mmHg
HCO3: 26 mEq/L
Sputum and blood sample positive with S. pneumoniae
JA is a 68 yo male pt who came into the ED via ambulance this morning. JA was found to be SOB and difficult to arouse by his wife prior to coming to the ED. His wife reported JA has been complaining of fatigue, chest pain, SOB and fevers for the last 2 weeks. VS are as follows: BP: 100/58; HR: 120; RR: 9; O2: 78%; T: 102.4. Pt is difficult to arouse; responds to painful stimuli. Pt is sinus tachy on the monitor with HR in the 120s. S1S2 is present. Cap refill is 3 seconds. Skin is tenting. Upon auscultation, crackles are present in the upper lung lobes and the right lower lobe. Lung sounds in the left lower lobe are diminished. Respirations are labored and nasal flaring is present. RR is 9-10 with sats at 78% on RA. Pt put on 2L nasal cannula, which increased the pt’s sats to 85-87%. Venturi mask 4L applied; the pt’s sats increased to 89-90%. Pt has a productive cough with thick, yellow sputum. Chest x-ray taken. Abdomen is soft and non-tender. Bowel sounds are hypoactive. Wife reports that pt’s last BM was 2 days ago. Pt’s wife reports he is continent of urine and voided last night before bed. Pt’s skin is intact, warm and dry. Awaiting lab results and chest x-ray results.
