Biographical Data Name Maxwell Robison

D.O.B- 06/ 07 /1940 Ethnicity: Indigenous Australians Religion: Salvation Army Education Level: Finish High School Occupation: Nil Chief Complaints A 72- year old smoker presented to the Emergency department 25/ 05/ 2012 with a two days history of productive cough with green sputum, shortness of breath ,fever difficulty lying on side due to pain. Physical examination on admission reveals a temperature of 38.4 C, BP 140/ 80mmHg, heart rate 85, and a respiratory rate of 20 breaths per minute. His oxygen saturation is 94%at rest. Lung sounds are dull with crackles at the right base. Chest X-ray reveals a Right lower lobe infiltrate .Physical examination is performed by medical officer on admission which indicates right lower lung pneumonia.

Vital signs BP- 108/78 mmhg

HR- 84/m RR-20/m Temp 36.8 SPO2: 95% Pain 6/10 Glass coma scale: 15/15 oriented, alert. He is able to speak full sentence. Current Regimen Gnetamycin IV daily Azithromycin 500mg daily Ceftriaxone IV 1g BD Augmetin duo forte Roxithromycin 150mg BD Slow K BD

Past Health General: relatively good Immunizations: flu vaccine yearly, and up to date. Infectious diseases: childhood illnesses

Allergic to penicillin- developed a diffuse rash after an injection 20 years ago. Illness: COPD Surgeries Tonsillectomy Wisdom teeth removed Physical Assessment Skin Skin is pale in colour, dry and elastic. No lesions or excoriations noted. Sprinkling of freckles noted across nose and cheeks. Head and Neck - Face smooth, oval and symmetrical head. Head symmetrically hard, round and smooth without bumps or lesions. Temporomandibular joint palpated with full range of motion, no tenderness. Neck has controlled, smooth full range of motion of neck. Lymph modes nonpalable. Thyroid glands nonvisible but palpable when swallowing. Trachea in midline.

Eyes and Ears Eyelids in normal postio with no abnormal ptosis or widening. No discharge redness and crusting noted on lid margins. Sclera and conjunctiva looks smooth and moist. No lesions or redness. No redness and swelling on lacrimal gland. Pupils are equal in size reactive to accommodation and light. Ears are in normal size bilaterally. No lumps, nodules, skin smooth and no discharge. No tenderness on palpation. There is moist yellow cerumen in external.

Nose and Sinuses-

physical abnormalities detected on external nose.

Sinus and airway clear in both nostrils. No smell abnormalities. Nose is dry due to oxygen via nasal prong. No drainage. Mouth and Throat lips smooth, but dry without lesions. Buccal mucosa moist pink, no exudates. Yellowish teeth front four teeth are missing. Equal bilateral strength in tongue. Soft palate is smooth and pink. Frenulum in midline.

Arms, Hand and Fingers -

Full ROM in both wrists and elbows.

Fingers warm to touch with brisk capillary refill. Brachial, radial and ulnar pulses regular and strong. Reflexes normal. Heart No bruits auscultated over carotids. Carotid pulse equal bilaterally. Jugular venous pulsation disappears when upright. Apical impulse palpated in the fifth ICS at the left MCL, Apical pulse 74bpm, regular rhythms. Thorax and lung Resp -20 per minute relaxed. No bulging or No pain or

retraction of interspaces. Chest expansion symmetric.

tenderness on palpation. Dull sounds present in right lower lung. Abdomen - no lesions, scars and rashes on abdomen. Abdomen symmetric and flat with no lumps or bulges. Bowel sounds are present in all four quadrants. Umbilicus area free of swelling bulges and masses.

Musculoskeletal -

Gait smooth with equal stride and good base of

support. Full ROM with no tenderness, pain and crepitus. ROM of lumbar spine and cervical. Lower and upper extremities symmetric without nodules, lesions swelling or deformities. Full ROM against resistance and gravity. Lifestyle and Health Practices Marital status - Single Living Arrangement He lives alone and renting a unit. Sleeping patterns - 8 hrs sleep during night Exercise Regime - walking every day ADls- He ambulate himself without any support. He cooks by self. Use of recreational drugs, alcohol, nicotin- He is smoking from age 12. He drinks two bears daily. He is planning to stop smoking and alcohol.

Diagnostic Tests Chest X-ray - infiltration Full blood Count elevated neutrophil count Blood culture positive for infecting organism Sputum culture growth of infecting organism CT scan Urine antigen testing Interdisciplinary Team and Discharge Planning Follow entire course of prescribed medications Get plenty of rest and drinks a lot of fluids (water) Avoid pollution

Physiotherapist to conduct deep breathing exercises with patient to prevent any complications. Follow up all appointments