Age/ Sex. 87years old Male.
Name of patient : Bigspin, Shit.
Attending Doctor: Knowingly, Heaven.
Medical Records # Q0000999000
Account number Q40000000050.
Location Telemetry floor.
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.
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.