Keith Johnson is a 65-year-old male with a history of chronic heart failure, HTN, high cholesterol, coronary artery disease (CAD) and Diabetes Mellitus II. He has a 42-year history of smoking 1 pack of cigarettes per day, quit 3 years ago. He is a retired truck driver who lives in a retirement community. He was brought into the emergency department (ED) by a friend after complaining of a massive headache, 10 out of 10, which felt like a “tight headband” around his head.
Mr. Johnson stated that his pain had increased as the day progressed. Vital signs upon intake revealed the following: 188/104, 108 BPM, 22 RR, 93%, 99.2F, when questioning the patient about the events leading up to this morning, he stated that he did not take his “water pill” or medications that his doctor prescribed. He added that he stopped the water pill because he keeps going to the bathroom, and is unable to sleep at night. He states he is on several heart medications. He did not bring any of his medication with him to the emergency department ED.
Physician’s orders included: