Patient Data for NR226 RUA Patient:
Patient History:
Ben Smith is a 75-year-old retired farmer from Southern Illinois. He is widowed and has 3 adult children who live
out of state. He is in an LTC for rehab following hospitalization. He has a 60-year history of smoking 2 PPD of
cigarettes. He fell 3 months prior to his hospitalization but did not sustain any injuries.
He was admitted to the hospital for an acute exacerbation of COPD. He also has a history of COVID in 2020,
HTN, and anxiety.
Medications:
• Acetaminophen 325mg PO Q6 hours PRN
• Albuterol inhaler, 2 puffs once daily
• Ipratropium bromide nebulizer Q8 hours PRN
• Lorazepam 5mg PO Q12 hours
• Nicotine patch, change every 72 hours
• Prednisone 30mg PO BID
• Multivitamin daily
Labs:
• Sputum culture and sensitivity- results showed no infection
• UA/UC- WNL
• CMP- WNL, except for potassium of 3.4 mEq/L
• CBC- WNL, except for platelets of 140k/mL
Imaging:
• Chest x-ray: shows focal consolidation in right lower lobe, suggestive of pneumonia
• Hyperinflation of lungs with flattened diaphragm consistent with long-standing COPD
• EKG: normal sinus rhythm with rate of 90 bpm
Assessment Data:
• Please be sure to fill in each system, including normal findings
• I will allow you to “make up” data that you would think would be abnormal in a patient like this, think of
findings especially in the following systems:
o Respiratory, cardiac, musculoskeletal, neuro
• Vital signs:
o Temp: 100.6 F, PO
o RR: 22 breaths/min, shallow
o HR: 90 bpm, regular
o BP: 145/90
o O2: 91% on 2L NC
o Pain: 7/10, intermittent, chest and upper back
Miscellaneous:
• The patient states that he hates hospitals and doesn’t belong in a nursing home. He says he needs to
get back to his farm
• He is impulsive and has tried to get out of bed numerous times, even though he is a stand by assist with
a history of falls
• He is non-compliant with medications and has felt nauseated. He does not want to take any meds and
“does not need that dang breathing thingy- it’s stupid!” (The nebulizer)
• He states he “will not quit smoking, I’ve been smoking since I was 15 and it hasn’t killed me yet!”