Case Study

  ADMISSION DATABASE Name: Juan Perez DOB: 3/22 (age 29) Physician: Deborah Kuhls, MD get it on # Deat: TIME: TRIAGE STATUS (ER ONLY): 5 ? 7/1 ? 0730 ? Red ? Yellow ? Green ? albumin Initial alert Signs TEMP: RESP: SAO 2 : 39 ? 22 HT (in): WT (lb): B/P: PULSE: 5 ? 10 ? ? 225 ? one hundred fifteen/65 ? 90 go TETANUS LAST ATE LAST DRANK unknown unknown ? unknown oral ride COMPLAINT/HX OF PRESENT ILLNESS unresponsive ALLERGIES: Meds, Food, IVP Dye, Seafood: example of Reaction unknown PREVIOUS HOSPITALIZATIONS/SURGERIES unknown first psyche TO CONTACT: Name: N/A Home #: ladder around #: ORIENTATION TO UNIT: ? C each(prenominal) light ? television/telephone ? Bathroom ? Visiting ? Smoking ? Meals ? diligent rights/responsibilities opposite ARTICLES: (Check if retained/describe) ? Contacts ? R ? L ? Dentures ? Upper ? Lower ? jewellery: necklace ? Other: ? VALUABLES ENVELOPE: ? ? Va luables instructions INFORMATION OBTAINED FROM: ? Patient ? foregoing record ? Family ? Responsible party Signature Home medicaments (including OTC) autographs: A ? Sent homeB ? Sent to pharmacyC ? Not brought in Medication pane of glass Frequency Time of Last Dose Code Patient Understanding of Drug unknown Do you take all medications as prescribed? ? Yes ? No If no, why?

PATIENT/FAMILY floor ? Cold in past two weeks ? Hay febricity ? Emphysema/lung problems ? TB disorder/positive TB unclothe test ? Cancer ? Stroke/past paralysis ? thug attack ? Angina/chest pain ? Heart problems bump SCREENING Have you ha! d a blood transfusion? ? Yes ? No Do you can? ? Yes ? No If yes, how mevery pack(s)? Does eachone in your household smoke? ? Yes ? No Do you drink alcohol? ? Yes ? No If yes, how oodles? How much? When was your die drink? ? ______/______/______ Do you take any recreational drugs? ? Yes ? No If yes, type:______ Route: Frequency:______ ensure last used:______/______/______ ? High blood pressure ?...If you loss to get a full essay, order it on our website: OrderCustomPaper.com

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