IP Encounter Report MRN DOB Sex M Adm DC HP All Notes continued PLAN I have

Ip encounter report mrn dob sex m adm dc hp all notes

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IP Encounter Report MRN: DOB: Sex: M Adm: D/C: H&P - All Notes (continued) PLAN : I have discussed the case with the referring provider and the family and our plan is Bilateral VEPTR insertion Ribs 4/5, L2-3 Post procedure ice, rest and elevation were dicussed. Patient education regarding wound and/or cast care, and return to clinic precautions were discussed. Pain management with morphine was discussed with the patient and/or family. Michael R. Ballard, PA-C (MR # Printed by [103311] at 10/11/13 10:09 AM Page 5 Electronically signed by Ballard, Michael R. at 6:17 AM Electronically signed by Erickson, Mark A. at 10:35 AM
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IP Encounter Report MRN: DOB: Sex: M Adm: D/C: Consults - All Notes Physical Therapy Spinal Fusion Progress Note Treatment Time: AM- 0945-1030 x 3 PM- 1:00-1:30 x 2 Relevant Medical History : is a 9 year old male with a history of severely progressive early onset scoliosis. He underwent one level fusion L2-L3, placement of initial vertical expandable prosthetic titanium rib (VEPTR) implants from ribs 4 to L3, and expansion thoracoplasty/initial VEPTR lengthening on PT Progress Assessment/Plan : did a great job on his first day post-operative, despite having had a difficult morning due to pain and anxiety leading to increased respiratory distress and having had an RRT called prior to therapy session. His mobility was limited during the morning session to bed mobility and sitting at the edge of the bed due to short oxygen lines and need for high flow heated nasal cannula. He progressed to a stand pivot transfer to bedside chair in the afternoon. Continue inpatient physical therapy twice per day until all goals met. Pain: 1-2/10 (verbally reported by patient) in a.m., 2-7-4/10 in p.m. session Intervention for pain: Clinician bolus, patient controlled analgesia and oral pain medications all given prior to morning session, oral pain medication and patient controlled analgesia in p.m. session Pain at end of session: 0/10 in a.m., 4/10 in p.m. Post operative Day 1: Patient transferred to bedside chair: Yes Goals and Progress : 1. will logroll with minimal assistance Progress: Moderate assistance to log roll this morning. 2. will require minimal assist from caregiver with transitions sidelying to sitting and sitting to sidelying Progress: Moderate assistance to go from sidelying to sitting at the edge of the bed in the morning. Able to sit with close guarding for safety x 5 minutes, mild complaints of nausea prior to sitting, but no complaints of pain or nausea once sitting. 3. will ambulate 250 feet with stand by assist from caregiver Progress: Not addressed today, did sit to stand and stand pivot transfer from bed to wheelchair with maximal assistance due to bed height and patient's complaints of pain during p.m. Session. Father of child and nurse reported feeling safe and comfortable with assisting patient back to bed after therapist reviewed and demonstrated proper technique.
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  • Spring '14
  • CherylA.Wenger
  • Trigraph, Mark Erickson, Brien M. Rabenhorst, •HYDROmorphone, •ondansetron

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