Please follow your facility policy and procedures.

Age/ Sex 75years Male.

Attending doctor: Godcreate,Beggins.

Patient name:Vaporme,James.

Chief Complaint: Trauma.

Secondary diagnosis :dm,htn,hypothyroidism, esrd.

Stated complaints: Falls, Spinal fractures.

Arrival time:1036am. June 6th 2001

Triage time 1037am.


Nurse :Amy Lovegod,RN.

Vital signs 1039 am.

Temperature 97.8,

pulse 104,

BP 123/72.

02 Saturation RA =96%.

List of patient Medications.

Allopurinol (Zyoprim) 300mg tablet daily at 09am.

Losartan(Zocor)100mg po daily at 09am.

Meropenem(MERREM) 500mg intravenously Q24hours.

Haldol 0.5mg po daily 1700.

Acarose(Precose)100mg po with meals.

Multivitamin 1 tablet each daily at 09am.

DiltiazemCardem ( immediate release) 30mg po bid.

Ferrous sulfate 325mg daily 09am.

Calcium acetate 667mg Three times a day with meals.

Simastatin(Zocor)20mg at bedtime.

Lofibra 20mg po at bedtime.

Ancef 1gm IV infused, by RN Jacob,Esen.

dilaudid 1mg IV Q4hours prn severe pain,given 12pm,by RN Jacob Esen.

Zofran 4mg intravenously Q4hours.

0.9NS infused 1000mg IV bolus given by Jacob Esen.


Chest xray of head,pelvic xray done.

CT scan of head done,

C T scan of abdomen done.

Code status Full code.

Isolation precautionary measures : Standard precautions.

MRSA swabbed in Emergency department. PLAN:

Vital sign Q4hours,

Neurochecks monitoring Q4hours.

Intake and output Q4hours,

Blood sugar monitoring Q6hours.

Elevate head of bed to 30°.

Spinal precautions, Immobilizer in place cervical spine,aspen collar in place,

urinal at bedside.

Strict : NPO .

Activity : Up with assistant. ,

Weight bearing status as tolerated. SCD in place to prevent blood clots.

Heparin 500mg TID.

Bacitracin ointment apply to all bruises twice a day.



Nephrology consult,

general surgery consult,

cardiovascular consult,

Case manager consult,

dietary consult.


CBC with differential,

Chem 7,Albumin, Prealbumin.


Wbc 6.8,

H/H 8.1/24.3,

K 4.6,Na=134,

plt=140(150- 350)

Coagulation PT 10.2,

INR 1.0.

(Normal INR to prevent recurrent Myocardial infarction (2.0to 3)

CT scan of the pelvic Results.

L2,L3,transverse process fractures.

T11 mild fracture, slight bruise to face,head and left elbow.

Head CT scan normal.

There is no abnormal findings.

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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