Mr B.B 35years old Male.

Brought in by ambulance to emergency room.

English Speaking.

Full Code.

Medical record number:


Admitting date 09/06/2004.

Status :Inpatient Admission.

Attending doctor:

Dr. Too Much.

Room 502211.

Admitting Diagnosis:

Motorcycle Accident.

Right Distal Humerus Fracture.

Right Acetabular fracture.

Past Medical History:

Right knee Surgery. Patient was splitting up lanes when a car going at a speed of 35 mph hit him and he fell on his right side.Luckily he had his helmet on to protect his skull.

CT scan of head is negative.

Encephalopathy. Right proximal Humerus fracture. Right acetabular fracture with superior posterior displacement of right femoral head.

Right foot numbness.


Right acetabular fracture repair.

Splinted of right shoulder and arm.

ORIF of right shoulder /arm in two days. Physical Therapist to work with patient.Immobolizer right upper Extremity. Dressing right hip and right arm.

Nonweight bearing to RUE and right lower Extremity.

Allergy: NKDA.

Diet : Regular diet.

Generalized pain to right knee, foot and right arm.

02 @ 2 Liter NC.

Bowel movement Ă— 2 today.

Voiding well using the urinal.


Dilaudid 2mg iv Q2hours prn pain.( For breakthrough)

Dilaudid 4mg po Q4hours prn pain.

Percocet tablets po Q4hours prn pain.

Hemoglobin 9.4

Hematocrit 24.7.

Transfer to Skilled nursing facility when Medically stable.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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