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88 y.o Male NKDA Full code 51kg (Meds: (Carvedilol, Pantoprazole …
88 y.o
Male
NKDA
Full code
51kg
MDX:
Spontaneous pneumothorax
20 fr. chest tube, water seal
PMH:
COPD
Diabetes Mellitus
with stage 3 CKD
HTN
Dementia and Alzheimers
Iron deficiency anemia
Potential NDX:
Impaired gas exchange
Activity Intolerance
Imbalanced Blood Glucose
Imaging:
Chest Xray:
5.9cm pneumothorax to R. apical lung. R. chest tube in position. Atelectasis changes within R. + L. lower lobes.
EKG:
Sinus tachycardia, low voltage QRS, Ventricular rate 118 bpm
Labs:
Increased WBC 12.0
Decreased Hgb 10.5 and Hct 33.2
Increased BUN 31
and Decreased eGFR 58
Elevated BG 157,
163,197, 229, 238
Meds:
Carvedilol
Pantoprazole
Sodium Bicarbonate
Hx of GERD and GIB
Insulin Protamine and Aspart
Senna tab
Prevent constipation
Tamsulosin
Hx of urinary retention
Quetiapine