Diagnosis : Tuberculosis, Hypertension,HyperlipidemiaPhysical ExamCarlos Mendez, 48-yr-old, Spanish speaking with no known past medical Hx. r/o tuberculosis , HTN Hyperlipidemia. Vital signs -Temp 99.1?F (37.3?C), BP 124/62 mmHg, pulse 77 beats per minute, RR 20 breaths, SaO2 91% on room air. Airborne Isolation is in place. Neuro assessment within normal limits. Skin moist, lungs with bilateral wheezes and coarse crackles (rhonchi). Blood-tinged mucous, productive cough. Diet as tolerated. IV maintenance fluids with D5 1/2 NS @ 150 mL/hr. X 3 hours then reduce the rate to 75 mL/hr. Expresses fatigue, fear, concern, and desire for recovery. Need a frequent reminder to stay in the room and maintain mask precautions. If family/visitors come, they will need education about airborne precautions. A Spanish interpreter is available at extension 61178. Dr. RondeauGeneral: Young male, looks older then stated ageHEENT: Depressed, pupils equally round and reactive to light and accommodationRespiration: Unilateral (left side) crepitationCardiac: Regular rate and rhythm, no murmurs, rubs, or gallopsAbdomen: Slightly distendedExtremities: No edemaSkin Excoriated, otherwise normalNeuro: Slightly altered, but baselineRadiologyChest X-ray showed infiltrate in the middle of left lung with diameter of 1.7 cm with signs of cavitation.Microbiology MicroBlood CultureNo growth at 5 daysSputum SmearGram Stain4 squamous epithelial cells,1 segmented neutrophils, no organismsAFS (acid fast stain)No organismsSputum CultureNo growth at 48 hrsMGIT (mycobacteria growth indicator tube) NegativeLaboratoryNa: 133Creatinine: 1.8K: 4.1WBC: 9.48 x 109/LCl: 96Hgb: 11.4 g/dL (114 g/L)Platelets: 149 109/L HIV test: NegativeRECOMMENDED NURSING DIAGNOSISDeficient Knowledge: Disease and Transmission R/T——– as evidenced by —————Risk for infectionIneffective Health ManagementIneffective Breathing PatternAnxietyMEDICATIONSrifampin 300 mg capsuleSIG: give 2 capsules (600 mg) by oral route once a month for 6 months with water, 1 hour before or 2 hours after a mealisoniazid 100 mg tabletSIG: give 3 tablets (300 mg) by oral route once dailyLipitor 20 mg tabletSIG: give 1 tablet (20 mg) by oral route once daily at bedtimeacetaminophen 325 mg tabletSIG: give 2 tablets (650 mg) by oral route every 6 hours as needed 12/09/2019 amlodipine 10 mg tabletSIG: give 1 tablet (10 mg) by oral route once daily in the eveningascorbic acid (vitamin C) 500 mg tabletSIG: give 1 tablet (500mg) by oral route dailyhydralazine 50 mg tabletSIG: give 1 tablet (50 mg) by oral route 2 times per day with food Lipitor 20 mg tabletSIG: give 1 tablet (20 mg) by oral route once daily at bedtimeTREATMENT/MONITORINGairborne precautionsMonitor vital signsSputum for AFB X 3, Chest X-ray AP, LAT VIEWMonitor weights weekly/monthlyPlease write:Two nursing diagnoses: Nursing Diagnosis #1 and Nursing Diagnosis #2:ASSESS, PLAN: EXPECTED OUTCOME, NURSING INTERVENTION, RATIONALE FOR INTERVENTION, EVALUATE (Progress toward outcome).Note significant results of Lab results and/or medical testing. Include EKG sheet or telemetry strip if on monitoring.  Medical History: Surgical History:   Admitting Diagnosis: Subjective DataObjective DataAlso, if you can please name all meds prescribed.Health ScienceScienceNursing NURS 22000

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