Overview
- Name: Kirby BaxterAge: 36 yearsProvider: M. McCall MDAllergies: NKDACode Status: Full CodeAdmit Wt: 190 lbs (86.2 kg)BMI: 27.3
- Other
09/30 0800Client Information:
Medical History: Transient ischemic attack, type 2 diabetes, depression, pulmonary embolism
Social History: Smokes 1 pack/day cigarettes
- Name: Kirby BaxterAge: 36 yearsProvider: M. McCall MDAllergies: NKDACode Status: Full CodeAdmit Wt: 190 lbs (86.2 kg)BMI: 27.3r
- Lab & Diagnostics
- Other
DIAGNOSTIC TEST RESULTSDateDiagnostic TestFindings09/30 0920 Computed Tomography (CT) Focal cord enlargement at the level of trauma on sagittal T4. Suggested MRI (magnetic resonance imaging) for more detailed imaging.
PROVIDER PRESCRIPTIONS & NOTES09/30 0802Prescriptions:
- Insert two large-bore peripheral IVs
- 650 mg of acetaminophen by mouth q6h PRN for pain
- Apply 100% oxygen via nonrebreather mask
- Complete full neurologic exam
- Electrocardiogram now
- Insert indwelling urinary catheter
- Out of bed to chair three times daily
- Regular diet
09/30 0925Prescriptions:
- Morphine 2 mg IV push q3h PRN for pain
- 0.9% NS 1000 mL IV fluid bolus – infuse over one hour
- Collect urine sample
- Orthostatic vital signs - once
- CBC level
- Lower the head of the bed
- Flowsheets
- Provider
- Lab & Diagnostics
- Other
VITAL SIGN TRENDDate TempHRRRBPSpO2O209/30 074598.0 °F (36.7 °C)462888/5299%2L/NC09/30 0930 98.0 °F (36.7 °C)5816 100/80 99% RA
Age: 36 years
Provider: M. McCall MD
Allergies: NKDA
Code Status: Full Code
Admit Wt: 190 lbs (86.2 kg)
BMI: 27.3
NURSING ASSESSMENT & NOTES09/30 0750
Neuro/Cognitive: Alert, oriented to person, place, time, and situation. Slow to answer questions.
Cardiovascular: S1 and S2 sounds present. Denies chest pain. Sinus bradycardia.
Respiratory: Breathing rapid. Equal chest rise and fall.
Genitourinary: 16 F indwelling urinary catheter draining yellow, clear urine.
Neurovascular: Numbness and tingling along with decreased sensation to lower extremities.
Pain: Rates 9/10 pain. “My neck is killing me!”