Please follow up with doctor orders,facility policy and procedures.
A 45years old male with AMS,right sided weakness. Diagnosis Auto vs Peds.
Possible suicide attempt.
Alert and oriented to place, and self.( Alert and oriented x2)No signs of delusion.
Talking about imaginery wife with two handsome boys .Eloped from Skilled Nursing Facility. Left Subdural hematoma, left subachnoid hemorrhage, displaced left skull communuted extension into left mastoids.
Bleeding from left area of the skull resolved,nondisplaced fracture of the left Zygoma,media and lateral ptergoids resolved.
Bilateral occipital condyle fracture.
Weight bearing as tolerated,daily.
PT/OT, knee immobilizer in place.
Neck with Cervical Collar.
Carb Controlled diet.(Sit up during feeding ,assist with feeding)Accucheck Qac and Qhs.Sliding scales. Medications:
Latuda 40mg po Qday.
Cogentin 2mg 2mg po 1700.
Olanzapine 10mg po Qday.
Regular insulin 4units Qam( 30minutes before breakfast, and meal)
Left forearm 20guage saline lock Clean/Dry/Patent.
Discharge plans:
Patient will tranfer to SNF when bed is available.


Thank you very much.
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