434 CASE SCENARIO FALL AT HOME. (Witnessed)VOMITING/LETHARGIC/SLURRED SPEECH/UTI)

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.