Journal 2 - Macy Bundy C.L is a 34 year old African...

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Macy Bundy C.L. is a 34 year old African American male with a mother and an aunt, admitted to Cardinal Hill the weekend of September 8, 2007 for PT, OT, personal and family teaching he is in the spinal cord program. He received T2-T3 Spinal Cord Injury secondary to a gun shot wound when he was hit in the neck on 8/24/07, leaving him with paraplegia and a left scapula fx. The primary goal of CHRHs spinal cord program is to familiarize new injuries to living with a spinal cord injury, teaching family ADLs, so he can return home with assistance. VS: B/P: 118/76, P: 76, T: 97.9, RR: 14bpm, Sat: 99%, Blood Sugar: 115 GENERAL: (Height & weight unknown) overweight man reclined in his electric wheelchair sleeping in the therapy gym. Poor hygiene with odor radiating from him, long dirty nails, ashy skin; patient complaining of extreme pain today. (NORMAL FINDINGS: patient needs to have some dietary counseling, be bathed, with hair washed every few days, nails cleaned and cut and lotion applied to skin, pain should be monitored better). INTEGUMENT: Skin is free of breakdown. Elastic turgor. Dark pigments, dry, soft, and warm to touch (abdominal area covered in what seemed to be a very large ace bandage). (NORMAL FINDINGS J ). HEENT: Head normocephalic, symmetrical, proportional to rest of body. Hair course, dark, unevenly distributed in dreadlocks. Corneas clear, irises dark brown, conjunctivae clear, pink, with no discharge, sclera white with a tent of yellow. Tragus intact, no lesions present and auricle nontender. External auditory ear canal dark, intact, with no lesions or serulin present. Acoustic nerve intact. Nose same color as body, smooth, no nodules or
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Macy Bundy masses present. Septum intact and on the midline with turbinate’s present and symmetrical. No change in smell. Lips symmetrical, smooth, dark & moist, with out lesions. Multiple teeth replaced by false gold teeth. Oral mucosa pink and moist with hard
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Journal 2 - Macy Bundy C.L is a 34 year old African...

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