summer care plan

Name: James Daniels

Date of birth: January,17 1986

Allergies: NKDA

Compliant: Fatigue, fever, and malaise for the past 3 weeks

History:-

Temperature: 101-104 in the past week

Temperature on admission: 100.2 orally

Taking acetaminophen and ibuprofen every 4-6 hours at home

Medical history: Pre-hypertension and Raynaud’s disease

No past surgeries or medicine at home

Current:

BP=113/80

Temp=101

O2 sat=95%

HR=110

R=18

Labs:

PH=7.2

Lactate=7

WBC=

Blood Cultures=

Chem 7=

 

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