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Patient Name: Emily Montgomery Occupation: Retired Sex at birth: Female Admit from: Home ALLERGY: NKA Primary Payer: BCBS Secondary Insurance: BC/BS SSN#: XXX-XX-XX22 PATIENT DEMOGRAPHICS Date of Birth: 10/13/1965 MRN: 0012101 1. Pneumonia 2. Malnutrition 3. R/O Depression PAYER INFORMATION Primary language: English Race: C Sex identify with: Female Age: 55 Address: 1000 Wisteria Lane, Orchid, Wisconsin Group #: 0010101 Group #: Type of Claim: Primary Physician: Dr. Jack Wall Chief Complaint: Shortness of breath, cough, fever MEDICAL PROVIDERS Lee Montgomery (son) - (847) 123-4567 Jane Austin (daughter) - (815) 098-7654 CONTACTS Admission Date: 01/12/2021 Marital Status: W Policy Number: 009054321233 Policy Number: XXXXXX0002 Advance Directives: NONE LIST OF DIAGNOSIS Religion: ND Status: Admit to Medical floor
Emily Montgomery is a 55-year-old woman admitted with a diagnosis of pneumonia and malnutrition. Mrs. Montgomery was brought to the emergency department by a friend. She lives alone and does not work outside the home. Her husband of 30 years died about 1 year ago. She has a son and a daughter; both are married and live about 100 miles away. Physical examination reveals a thin, frail-appearing woman in mild respiratory distress. She is receiving oxygen at 2 L/min, intravenous fluids of 5% dextrose, and water with 40 mEq of potassium added. She is on a full liquid diet with orders to push oral fluids. She is 5'6" tall and weighs 103 lb. She states she has had a poor appetite for the past year and usually eats one small meal daily. Mrs. Montgomery reports a 40-lb weight loss. Laboratory values: hemoglobin 9.7 g/dL, hematocrit 30.1%, albumin 2.8 g/dL Mrs. Montgomery was admitted to the Medical floor with the following orders: 1. Diet: Full liquid diet 2. Dietary consult 3. Vital signs every 4 hours 4. Intake and Output every 4 hours 5. 02 at 2 L/min via nasal cannula, titrate to maintain SpO2 above 92% 6. D5 W + 40 mEq KCl at 80 mL/hour continuous 7. Levofloxacin 500 mg IV every 24 hours X 7 days 8. Multivitamin ltab po daily 9. Refer to psychiatrist to r/o depression