436 CASE SCENARIO.FALL SPINAL FRACTURE.( EMERGENCY ROOM ROOM REPORT)

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. Insurance:Medicare. Nurse :Amy Lovegod,RN. Vital signs 1039 am. Temperature 97.8, pulse 104, BP 123/72. 02 Saturation RA =96%. List …