revised care map - osteomyelitis.docx

revised care map - osteomyelitis.docx - SOUTH TEXAS COLLEGE...

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SOUTH TEXAS COLLEGE PHYSICAL ASSESSMENT: Ht: 180 cm Wt: 77.8kg BMI: 24 Allergies: NKA Vital signs T: Not assessed P: Not assessed RR: Not assessed B/P: Not assessed Pain: 8/10 O2Sats: Not assessed Abnormal physical assessment findings/problems: Patient states that pain is at a 8 out of 10. Abnormal psycho/social findings/problems: Patient stated “I’m not going to legends” to son when speaking about discharge. Patient also states, “I’m going to be on bed rest for the rest of my life” ETIOLOGY: Risk Factors: Recent orthopedic surgery, infection, trauma, especially resulting in fracture or deep puncture wounds, older age, obesity, immunosuppression, diabetes, long-term steroid therapy, sickle cell disease, IV drug use, vascular insufficiency, animal bite, central line use Causes: Acute infection originating elsewhere in the body, Escherichia coli , Fungi or viruses, Minor traumatic injury, Proteus vulgaris , Pseudomonas aeruginosa , Staphylococcus aureus , Streptococcus pyogenes PATIENT DATA Patient Initials J.C. Age: 58 Sex: Male Race: White Code Status: Full Code Date of admission: 06/12/2019 Admitting diagnosis: Lumbar Osteomylitis History of Present Illness (HPI): Patient states he’s had sever lower back pain for the last three year that went untreated until this year, first admission date at DHR is 5/29/2019 with Dr. Patel. Lumbar wound debridement was scheduled for 06/12/2019. Patient is being kept for observation and is awaiting a biopsy procedure that is scheduled for 06/21/2019. Medical & Surgical History: Medical: Obesity, abnormal gait, chronic osteomyelitis, reduced mobility and history of TB in 2012 Surgical: n/a Social History: Patient denies any alcohol or drug use.
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  • Spring '16
  • Gloria Seno
  • acute pain, Suffering

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