Mr. Jax Marlboro
Respiratory Care Pharmacology
Fall 2015
Joni Sims
Presenting History and Physical:
Mr. Marlboro, a 65 year old African American male who is being seen in the emergency room with complaints of fatigue, shortness of breath, and wheezing while trying to accomplish simple daily task. He also complains of a cough that is becoming more frequent and persistent.
Mr. Marlboro has a history of asthma as a young adult and was diagnosed with hypertension at the age of 40. Mr. Marlboro stated that he has been a smoker since the age of 18 and smoked 1 pack of cigarettes a day until he quit 3 years ago. He has not been treated for his asthma in several years and assumed that he grew out of it. He is not on any medications since he lost …show more content…
Marlboro states that he is breathing has improved and is responding to all medication. HR- 120, RR-21, BP 140/81, temp 99.0, pulse oximeter reads 95%. Over the next 24 hours the patient steadily improved. Breath sounds, vitals, and labs are back to normal for a patient with COPD. Patient will continue 500mg Azithromycin for the next 6 days. His oxygen has been lowered to 2L/min. The attending doctor has ordered a nutritionist and a counselor from the GOLD foundation to educate and give Mr. Marlboro support before he is discharged.
Labs Results Normal-men (Web MD)
RBC 5,500 5,000-10,000
RBC 5 million 4.5-5.5 million
H/Hb 14% 14-17.4(g/dL)
Neutro 60% 50%-62%
Lymphocytes 25% 25%-40%
Chest x-ray done
Sputum Culture done
Discharge:
Mr. Marlboro has been educated on the risk of emphysema and has acknowledged that smoking may have been the cause. He has been referred to a Pulmonologist and a Cardiologist to keep his diseases under control. Mr. Marlboro has been sent home with a list of medications with directions and possible side effects. He has been instructed to make a follow-up appointment with his primary health care
Respiratory Care Pharmacology
Fall 2015
Joni Sims
Presenting History and Physical:
Mr. Marlboro, a 65 year old African American male who is being seen in the emergency room with complaints of fatigue, shortness of breath, and wheezing while trying to accomplish simple daily task. He also complains of a cough that is becoming more frequent and persistent.
Mr. Marlboro has a history of asthma as a young adult and was diagnosed with hypertension at the age of 40. Mr. Marlboro stated that he has been a smoker since the age of 18 and smoked 1 pack of cigarettes a day until he quit 3 years ago. He has not been treated for his asthma in several years and assumed that he grew out of it. He is not on any medications since he lost …show more content…
Marlboro states that he is breathing has improved and is responding to all medication. HR- 120, RR-21, BP 140/81, temp 99.0, pulse oximeter reads 95%. Over the next 24 hours the patient steadily improved. Breath sounds, vitals, and labs are back to normal for a patient with COPD. Patient will continue 500mg Azithromycin for the next 6 days. His oxygen has been lowered to 2L/min. The attending doctor has ordered a nutritionist and a counselor from the GOLD foundation to educate and give Mr. Marlboro support before he is discharged.
Labs Results Normal-men (Web MD)
RBC 5,500 5,000-10,000
RBC 5 million 4.5-5.5 million
H/Hb 14% 14-17.4(g/dL)
Neutro 60% 50%-62%
Lymphocytes 25% 25%-40%
Chest x-ray done
Sputum Culture done
Discharge:
Mr. Marlboro has been educated on the risk of emphysema and has acknowledged that smoking may have been the cause. He has been referred to a Pulmonologist and a Cardiologist to keep his diseases under control. Mr. Marlboro has been sent home with a list of medications with directions and possible side effects. He has been instructed to make a follow-up appointment with his primary health care