SOLVED345

S – Situation Eli Yoder, Geriatric Admitting physician: Dr. Wise Room 356, Telemetry unit, Tech General Hospital B – Background Admission Diagnosis: Shortness of breath, tachycardia Past Medical History: Hypertension, Heart failure, Lung cancer with metastasis to the bone (ribs) Home Medications: Metoprolol 25mg PO daily, Lisinopril 10mg PO daily, furosemide 40mg PO daily, Potassium 10mEq PO daily OTC/Supplements: Not Assessed Allergies: Iodine/Shellfish Height: 5’9″ Weight: 176 pounds Date of Birth: 7/21/1951 Code Status: Full Code A – Assessment History of present illness: Eli Yoder was admitted from the emergency room to the cardiac ICU 5 days ago with shortness of breath and tachycardia. The patient’s condition improved with treatment, and he was transferred to the telemetry unit today. Eli was diagnosed with lung cancer 11 months ago and developed heart failure 6 months ago. Eli has been receiving chemotherapy. The patient’s overall condition has been declining over the past few months. The patient and family were visited by a Palliative Care provider and are now requesting information about the advance directives. The patient will likely be discharged home within the next two days. Physical Examination: General: Alert and oriented x3 Neuro: Within normal limits, moves all extremities Chest: S1S2,
SCIENCE
HEALTH SCIENCE
NURSING

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