Reference no: EM133724068

Question

Review of the medical record shows that the patient is an elderly male patient who has been admitted and has been treated for community acquired pneumonia along with COPD exacerbation. The patient does have a longstanding history of COPD. However, he does not use oxygen at his independent living home. He has made improvements overnight. The night prior to admission, the patient needed to use the rest room and did not use his walker. He attempted to walk to the rest room on his own and sustained a fall. He stated that he just felt weak. He bumped his knee and his elbow. This morning, he denied any headache, back pain, or neck pain. He complained mostly of right anterior knee pain for which he had some bruising and swelling. OBJECTIVE: VITAL SIGNS: The patient's max temperature over the past 24 hours was 99.3 degrees; his blood pressure is 148/77, his pulse is 87 to 106. He is 95% on 2 L via nasal cannula. HEART: Regular rate and rhythm without murmur, gallop, or rub. LUNGS: Reveal no expiratory wheezing throughout. He does have some rhonchi on the right mid base. He did have a productive cough this morning.