CASE SCENARIO 431. ORTHOPEDIC/TRAUMA.

Follow your facility policy and procedures.

Age/Sex :66years/Male.

Unit :Q0021219998.

Admission Date: 05/12/13.

Status Inpatient: Admission.

Attending Doctor: Tumtum,Worry.

Patient name:Tony Golden.

Location : Orthopedic/Trauma department.

Room 44326.

Primary Diagnosis: L3,4,L4,5,L5S1.

S/P L4,5 surgery 05/14/13.TLIF( Transforminal interbody fusion)Spinal fusion surgery, awaiting physical therapy. TLSO Brace at the bedside. Blisters anterior chest, abrasions right and left elbows, incision posterior back.Back pain.

Secondary diagnosis: Hypertension, Gout.

Risk for fall : Yes.

Isolation precautions: Universal PRECAUTION.

Advanced directive:No .Copy of advanced Directive in the chart.

02 at 2liter NC.

Transportation style: Bed.

Code status: Full code. Lethargy.

Allergy: NKDA.

Diet: NPO ex Medication.

Tube feeding: None.

TPN : None.

Ngt to right nare for decompression of stomach. Tongue remains swollen.

CT Scan with contrast today.

BM: Three loose stools today.

Incontinent of bowel.

Foley catheter in place. 16 fr.Strict intake and output.

IVF: D51/2NS at 75ml/hr left upper arm.

Dilaudid 0.5mg IV Q3hours prn pain.

Morphine 2mg IV Q8hrs prn pain.

Norco 10/325mg 1tablet Q6hours prn pain via ngt.

Zosyn 3.375gm IV Q8hrs.

Plans:PT/OT evaluation and treatment. (TLSO BRACE at bedside)

Discharge to SNF when stable.

LABORATORY TEST RESULTS.

H/H 9.4/25.8

Na = 136.

Potassium =4.1.