Date: October 3, 2022

Time: 8:00 AM
Department: ER

Patients Profile
Name: Maria Santos
Age: 25
Sex: Female

Case Scenario:
Ms. Santos is a 25-year old caregiver, who has just got out from the night shift when she
manifested general body malaise, chills and shortness of breath. She is aware that presence of
these signs and symptoms is indicative of infection. She decided to drop by at the Emergency
Room Department to ask for some prescriptions.

V/S results are as follows: BP- 130/70, RR- 30, P- 98, and T – 38.6 º C. Ms. Santos verbalizes
having loss of appetite, (+) productive cough, to a yellow to greenish phlegm for 5 days now, but
needs to report on duty because she is a single mother to a 3-year old toddler. Further assessment
findings by the doctor reveal presence of slight cyanosis with oxygen saturation of 90%. Upon
palpation Ms. Santos skin is warm to touch.

Oxygen 2Liters/min per nasal cannula was ordered together with Paracetamol as antipyretic.
Paracetamol 500 mg 1 Tab was given orally, 30 minutes after giving Paracetamol, Temperature
is rechecked and was decreased to 38.0 º C. Diagnostic exams were STAT CBC, Urinalysis, and
Chest X- ray. Ms. Santos is advised to rest and is for admission. Venoclysis started – D5NM 1L
to run for 8 hours and was regulated at 31drops per minute or 125ml/hour. Laboratory results
show presence of infection.

At 12Noon vital were again taken, the results are as follows: BP- 120/70, RR- 25, P- 90, and T –
38.2 º C and oxygen saturation of 95%. While in the ER Ms. Santos were able to defecate or
moved her bowel once to a soft formed stool, urinated 2x moderate in amount, yellowish in color
approximately 420 ml. She’s able to consume 2 slices of bread, 1 piece of medium-sized banana
and 750 ml of water, IV fluids infused is 500ml. Patient is remained on bed rest.

Impression: Pneumonia

Instruction:

Based on the clinical situation, formulate an FDAR charting identifying 2 (Focus) problems.

Submission of output will be on Wednesday October 5 @ 7AM together with your FHP.