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PATIENTASSESSMENTAge: __95__ Gender: ___Female___Resuscitation Status ___DNA___ Allergies___Fragrance, Perfume, Cologne, Cosmetics, Cinnamon, and Caffeine___Reason for Admission: _____Subdural Hematoma, Dementia, Malnutrition_____Medical Diagnoses: ______Hypertension, Osteoporosis, Asthma, Anxiety, GERD_________________________________________________________________________________________________________________Surgeries/Procedures and Dates: ___Unknow reason for Abdominal Surgery (Date: Unknown), Tonsillectomy to remove tonsils (Date: Unknown), Oophorectomy to remove one or both ovaries (Date: Unknown), Hemiarthroplasty on Left Hip to replace half the hip joint (Date: 2014) ______Past medical history____Pelvic Fracture (Date: 2019) ____________________________________________________________________________________________________________Current Orders:Diet_____Mechanical Soft, Thin Liquids_____ Activity_______Ambulates and eats on own_______Intake ______N/A_______ Output______N/A_______ Accu Cheks______N/A________Vital signs______T- 97.8 Degrees Fahrenheit, HR- 74, SpO2- 98, RR- 20, B/P- 162/48 R. arm, Pain- 0 __________Drsg changes/wound care_______N/A________Foley_______N/A________ NG/G-tube/PEG/PEJ______N/A______IV ________N/A__________ Reason for IV________N/A__________Other orders:_____4/2/19 STAT CT scan Pelvic area Reason: Patient had fallen___________4/7/19 Physical Therapy to Evaluate and Treat for 30 days Reason: Post-fall evaluation __________4/8/19 CT scan of head Reason: Post-fall check up__________10/1/19 Wanderguard in place Reason: to keep patient in the facility and to make patient is safe__________10/21/19 Mechanical soft diet and thin liquids, remove dentures during meals Reason: patient was at risk for aspiration__________10/25/19 Flu shot Reason: protocol of the facility and it is the flu season__________10/29/19 Cleanse the Left Lower posterior leg, apply bacitracin, and cover with dry dressing Reason: to prevent skin infection due to small abrasions in the leg_________________________________________________________________________________________________________________________________________________________________________________________________________________1STUDENT: ______Ariadne Abrica________ Date of Care: ___Nov. 14, 2019___
______________________________________________________________________________________________________Most recent ImagingFindings:(CXR? CT? MRI?)Type of Imaging (X-Ray, CT, MRI, etc)Body Area ImagedReason for testing and results of testCTPelvic ArePatient had fallen Results: Pelvic FractureCTHeadPatient had fallen Results: UnknownMost Recent Significant /RecentLabResults:(Chemistry? Hematology? Drug Levels? Coagulation tests?)DateLab TestResultsNormsComments10/7/19CBCAll normal except for MCHC (31) and MPV (13.4)MCHC 32-36%MPV 9.8-12.7 fLThe low MCHC could be because ofanemia.The slightly high MPV could be dueto infection, inflammation, or heavy blood loss.10/7/19Basic Metabolic PanelAll normal except for Glucose (114)Urea Nitrogen (32)GFR African American(49)GFR Others (49)Glucose 70-99 mg/dLUrea Nitrogen 8-23 mg/dLGFR African American 60-300GFR Others 60-300The glucose could be due to high amounts of sugar in the blood.The high urea nitrogen could be mean that the kidneys are not working properly.The GFR being low could also be because the kidneys are not working properly.