Name Neil Leary Explained for Students (Easy Guide)

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Name: Neil O’Leary Age: 83 years Provider: B. Yang MD Allergies: PCN Code Status: Full Code Admit Wt: 135 lbs (61.2kg) BMI: 18.8 4/1 1510 Nursing Note: Police officer escorting client to the ED reports a neighbor called for an elder well-check since they hadn’t seen the client outside in some time. Upon entering, they noted the interior of the client’s house was in disarray. Client appears disheveled, and his clothes and body appear and smell malodorous. Reports he hasn’t eaten a full meal in the past month and claims, “I am just not hungry.” He snacks on crackers and chips throughout the day. He explains eating alone is an unsatisfying experience. The client is angry and wants to leave without medical attention. Discussed the benefits and risks of leaving versus staying. He states he is willing to be assessed. 4/1 1515 Neuro/Cognitive: Alert, oriented x 3. Agitated. Denies suicidal ideation/homicidal ideation. Cardiovascular: S1/S2 auscultated. HR regular, even. Respiratory:Breath sounds clear in all lobes. Breathing regular and even. Gastrointestinal: Abdomen soft, flat, non-tender. Unknown last bowel movement. Client estimates 1-2 days ago. 4/1 1510 98.6 °F (37.0 °C) 88 20 137/82 97% RA 4/1 1530 Prescriptions: • CT head • CBC, CMP • Place two peripheral IV sites • Normal Saline 0.9% – 75 mL/hr IV continuous

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