Reference no: EM133662574

Problem

A.R., a 65-year-old Caucasian man, admitted to a medical floor for exacerbation of his COPD and emphysema. He has a PMH of hypertension, which has been well controlled by enalapril for the past 10 years. He was also diagnosed with pneumonia about 4 years ago. He presents as a thin, poorly nourished man who is having trouble breathing at rest. He reports productive cough of thick, yellow-green sputum. A.R. seems irritable and anxious when he tells you that he has been a two-pack a day smoker for 38 years. He C/O sleeps poorly and lately feels very tired most of the time. Social History: A.R. and his wife have a handful of pets that keep them company, and they consist of two dogs, one cat, two fish, and a hamster. Otherwise, no other significant history Allergies: No Known Allergy (NKA) VS: 1020F (oral) - 124 - 36 - 162/84; SaO2 89% on RA Repeat VS: 101.50F (oral) - 116 - 32 - 166/86; SaO2 90% on 2-3 L N/C Admitting Diagnoses: Chronic Emphysema with an exacerbation of COPD Admission Orders: Titrate O2 via N/C to maintain SaO2 @ 90% Diet: Regular diet as tolerated. Out of Bed (OOB) with Assistance Intake and Output (I/O) Chest X-Ray Labs: Arterial Blood Gas (ABGs) Complete Blood Count (CBC with Differentials Basic Metabolic Panel (BMP "Chemistry) Medication: Azithromycin 500mg IV q 24 hrs. x 2 days; then 500mg po x 7 days DuoNeb (albuterol & Ipratropium) neb Q4-6 Hrs. Enalapril (Vasotec) 10 mg po Q Am Prednisone 60mg po daily Doxycycline 100mg po Q 12hrs Tylenol 650mg po Q 4hrs PRN as needed for temp > > 100 F

What is the subjective data, Objective data, Assessment and Planning for the patient. Analysis Data should match the planning care.