Mrs. Xiong presented to ER with SOB and chest pain at level 3 during cough. On arrival, V/S T 101.2F, BP 90/58 mmHg, RR 32 bpm, HR 132 bpm, SpO2 85% on room air. On assessment, pt was dyspnea on exertion with unproductive cough. Pt was diagnosed with Pneumonia and Dehydration. Pt required supplemental therapy of O2 at 2-4L via nasal cannula to keep SpO2 at 95% or higher, 1000 mL 0.9% NaCl via IV infusion at 50 mL rate and completed Azithromycin in D5W via IVPB on 2/18 for day 1. She was then weaned off oxygen and to commence Erythromycin (400mg PO q12h) and Ibuprofen PRN analgesic (400mg PO PRN pain/q6h). Prescription meds electronically sent to preferred pharmacy. Received additional orders for Xray, Sputum culture and sensitivity, BMP, CBC, Blood Culture x2 with pending results. Pt and POA will be notified via phone call once results are available. Online access to medical chart set up w/ POA. Pt to remain on regular diet and bed rest with bathroom privileges as ordered. Received orders for discharge on 2/18/2023. Stable and discharged to home with self-care, daughter will provide support with home care. Initially, Pt was non-compliant with discharge instructions re home care. Provided discharge instructions and Pt education with a medical translator present and referral to social worker for transportation need during ff-up appointment on February 28, 2023. OT referral initiated. Advised to call provider if febrile w/ temp> 101.4F, presents with yellow, green, bloody, or smelly sputum, or increasing sputum production.
