fracture - revised care map.docx

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

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SOUTH TEXAS COLLEGE PATIENT DATA Patient Initials: V.F. Age: 65 Sex: M Race: White Code Status: Full Code Date of admission: 06/12/19 Admitting diagnosis: Closed right humerus pathological fracture related to Osteoporosis History of Present Illness (HPI): The patient complained of severe left arm pain and was seen at ER by Dr. Crous on 6/6/19, and hospital follow up for closed right humerus fixation was scheduled for 6/12/19. The patient was discharged with a splint for right arm but states it's uncomfortable. Surgery was performed 6/12/19. Patient is now in post-op for observation. Medical & Surgical History: C holecysetctomy – 2008 Open reduction internal fixation – 06/12/19 Social History: Patients smokes 1 pack a day for the last 30 years. Denies alcohol abuse. Denies drug abuse. Has his wife at bedside. Family History: Hypertesnion Diabetes PHYSICAL ASSESSMENT: Ht: 188cm Wt.: 102.9kg BMI: 30.3 Allergies: NKA Vital signs: T Not assessed _ P Not assessed RR Not assessed B/P Not assessed Pain: 9 O2Sats: Not assessed Abnormal physical assessment findings/problems: Not assessed. Abnormal psycho/social findings/problems: Patient states, “I don’t know how I’m going to be able to move around at home I cant even get up” ETIOLOGY: In elderly people fractures of the proximal femur, proximal humerus, and distal radius are commonly associated with osteoporosis. Risk factors are traumas, falls, osteoporosis, osteoarthritis, elderly, males. INCIDENCE The incidence of fractures is higher among young patients and elderly patients. Among young males, specifically those ages 15 to 24, most fractures are due to trauma (most commonly the tibia, clavicle, and distal humerus). DIAGNOSTIC TESTS: Lab results: high wbc count: 11.3 low rbc count: 3.59 low hgb: 9.8 low hematocrit: 30.3 PATHOPHYSIOLOGY:
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  • Spring '16
  • Gloria Seno

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