Review of her medical records indicates that she has had multiple hospitalizations in the last year for CHF/COPD exacerbation her last hospitalization was 8/28/16 at SLMC for COB and hypoxia. On 8/28/16 she had a left and right cardiac cath because of dyspnea and congestive heart failure. Her other medical history includes NIDDM, Afib, CVA with right sides hemiparesis, MI, GAD, dementia, bipolar, chronic ischemic heart disease, dysphagia, cognitive communication deficit, hyperlipidemia and GERD.
At todays visit she is found in her room lying in bed at Tiffany hall SNF. She is awake, alert; she appears SOB with difficulties verbalizing her self. She is oxygen dependent at 2l/min. She states that she is not doing well but was unable to elaborate due to her SOB. I spoke with the facility nurse who reports that the patient has had multiple hospitalizations for her CHF and COPD. She was last hospitalized on 8/28/16 for SOB. She has been declining functionally. A review of her …show more content…
She has dysphagia and is currently on a mechanical soft diet. She has total right sided hemiparesis from a past CVA. She also has an indwelling Foley catheter
At todays visit she is found in her room lying in bed at Tiffany hall SNF. She is awake, alert; she appears SOB with difficulties verbalizing her self. She is oxygen dependent at 2l/min. She states that she is not doing well but was unable to elaborate due to her SOB. I spoke with the facility nurse who reports that the patient has had multiple hospitalizations for her CHF and COPD. She was last hospitalized on 8/28/16 for SOB. She has been declining functionally. A review of her …show more content…
She has dysphagia and is currently on a mechanical soft diet. She has total right sided hemiparesis from a past CVA. She also has an indwelling Foley catheter