Fracture is when a traumatic injury occurs that affects the continuity of the tissue of the broken bone. Fracture is usually classified by the bone that is involved,the nature of the fracture and the part of the bone associated with the fracture. C6 fracture affects the lower end of the cord near the base of the neck.
KINGDOM OF GOD HOSPITAL LOS ANGELES CALIFORNIA 900000. INTERDISCIPLINARY KARDEX.
Age/Sex 25years old man.
Account number Q005634372.
MR #Q00038867544.
Admission date 📅2021.
Status : Inpatient admission.
Location : MedTelemetry.
Room # : 42121.
Attending doctor: Hussain Anderson.
Patient name: Dunkin Yam.
Primary diagnosis: C6 Fracture/ MVA.
Weight: 135lbs.
Height: 5feet 6inches.
Allergy: NKDA.
Isolation Status :
Standard Precautions.
Risk for fall: Yes.( Falls prevention protocol in place)
C-COLLAR all the time .
Suicidal risk: No.
Do patient have advance Directive: No.
Copy of advance Directive on the chart.
Diet Cardiac heart health diet.
Consistency: soft.
Transportation method: Bed.
02 at 2liter NC with Saturation 96%°F.
Side rails up.
Impaired skin intergrity: Yes.
Language barrier: No.
Doctor Orders:
C- Collar at all times.
0.9NS @ 75ml/ hour.
Colace 100mg po bid.
Azathioprine 200mg po 09am scheduled.
Norco 10/325mg 1tablet po Q4hours prn moderate pain.
Norco 2tablets 10/325mg po Q4hours prn severe pain.
Hydroxychloroquine sulfa 100mg po 09am.
Prednisone 20mg po 09am.
Echocardiagram today.
MRA of the C spine.
Physical therapy for evaluation and treatment.
Vital signs :Q4hours and prn.
SCD: Bilateral lower extremities.
Discharge plans:
Discharge home with family in 2days.
Nurses You Move Me 