Age/ Sex. 87years old Male.

Name of patient : Bigspin, Shit.

Attending Doctor: Knowingly, Heaven.

Medical Records # Q0000999000

Account number Q40000000050.

Inpatient admission.

Location Telemetry floor.

Room: 54404

Fall precautions protocols: Yes.

Code status: Full code.

Advanced directive No.Copy of advanced Directive on the chart.

Primary Diagnosis:Mechanical fall at home,hematoma back of his head.

PSH: Pacemaker left chest, LUE fistula nonfunctional. No thrill, no bruit ,feel like hard cord.Left subclavian Quinton catheter for hemodialysis. Hemodialysis Monday/Wednesday/Friday.

PMH: HTN,ESRD ON HD,CVA, TYPE 2 DM.Head small hematoma posterior right scalp, no bleeding.

Neck Cervical collar placed by EMT.

TTP posterior midline.

Cardiac Normal.

Respiration clear.RA.

Abdomen soft and non tender. Pelvic stable. Extremities: Moves all extremities, right upper Extremity contracted.

On Merrem antibiotics for UTI.Discharged from acute care hospital the previous day.

Plans Discharge to :

Skilled Nursing Facility.

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.

Leave a comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: