I

Is this Dr. Rosales? This is Nurse Rafaela, nurse

on ward. I am calling about Mrs. Del Valle, 65
years old female, who was admitted from long
ntroduction
term care facility.

S
I am calling because she has developed a
productive cough and small amount of thick,
creamy, yellowish phlegm.
ituation

B
Patient was admitted last evening from long term
facility. Patient was lethargic and confused.
Admitted with fever, T: 38°C, P: 92 (irregular),
ackground
RR: 28 (short and shallow), O2 sat: 94% and BP:
110/70.

A
Mrs. Del Valle slept 1-3 hours during the night
and remain confuse. She developed productive
cough with small amount of thick, creamy, and
ssessment
yellowish phlegm. Her morning vital signs are T:
38.2°C, P: 110, RR: 32, O2 sat: 92%and BP:
114/82. I think that the patient has Pneumonia.

R
Dr. Rosales, I believed that we must do the
following actions:
-Oxygen administration
ecommendation
-Complete bed rest
-Blood culture