History of present illness. why did she came in (story). Chief Complaint- S/S. Admitting Diagnosis- Medical Diagnosis . Pathophysiology of admitting diagnosis – 5 Sentences . Psychosocial assessment /Concerns (3 problems Bullet format)
pt is 23 year old female . Brought with ambulance from her boyfriend home. Pt called 911 stated she was afraid for her life because she just broke up with her boyfriend ., pt is paraplegic . she had an accident 4months ago. She stated she is out of food and drink . upon arrival pt HR 155 IV established. Pt didn’t eat anything almost 3 days. Pt is incontient.
she has wound Sacral 4 cm stage 4, color red sero-sanguinous. with palpable bone some areas of devitalized tissues .
sensory perception very limited,
pt presented from home to thrive pt has poor access to food and has lost dramatic amount of weight . Currently cachectic and severely dehydrated on presentation. Also noted to have severe hypercalemia which is likely component of bone breakdown, pt receving IV fluids and will be fed as tolerated. Pt also with decubitus ulcer which appears to be stage 4 with bone exposure. No surrounding erythema , or drainage and unlikely infected in the absence of leuocytosis,, fever or systemic toxicity.
Pt doesn’t work lives with boyfriend. Can’t afford food . inability to care herself.
History of High blood pressure.
No allergies.
medication : Gabapentin. IV D5W, Abilify , Amlodipine. Morphine IV push 2 mg PRN , Levonox
doesn’t smoke or drink. Vital signs
temp: 97.5. Resp. 16. HR 84, BP 126/76 (lying) 02 Sat 98 (room Air)
Chief Compient ” I don’t feel safe and I can’t provide myself food”
Diagnosis: Dehydration Hypokalemia
last BM 04/18
PT, OT, SW,
Lab Results : WBC 10.2, RBC. 3.96. Hemoglobin 10, Hematocrite 33.8, Glucose Random-70, sodium 130, potassium 2.9
If Something is normal and don’t have anything to write please write about risk factors to each normal finding and give teaching based on that
