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 stimulate COMPLAINT/HX OF PRESENT ILLNESS unresponsive ALLERGIES: Meds, Food, IVP Dye, Seafood: reference of Reaction unknown PREVIOUS HOSPITALIZATIONS/SURGERIES unknown first soulfulness TO CONTACT: Name: N/A Home #: hold up around #: ORIENTATION TO UNIT: ? C only light ? telecasting/telephone ? Bathroom ? Visiting ? Smoking ? Meals ? uncomplaining rights/responsibilities personal ARTICLES: (Check if retained/describe) ? Contacts ? R ? L ? Dentures ? Upper ? Lower ? jewelry: necklace ? Other: ? VALUABLES ENVELOPE: ? ? Valuables instructions INFORMATION OBTAINED FROM: ? Patient ? precedent record ? Family ? Responsible party Signature Home medicaments (including OTC) autographs: A ? Sent homeB ? Sent to pharmacyC ? Not brought in Medication window pane 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 chronicle ? Cold in past two weeks ? Hay fever ? Emphysema/lung problems ? TB disorder/positive TB peel off test ? Cancer ? Stroke/past paralysis ? fervour attack ? Angina/chest p ain ? Heart problems hazard SCREENING H! ave you had a blood transfusion? ? Yes ? No Do you bay window? ? Yes ? No If yes, how mevery pack(s)? Does eitherone in your household smoke? ? Yes ? No Do you drink alcohol? ? Yes ? No If yes, how lashings? How much? When was your die drink? ? ______/______/______ Do you take any recreational drugs? ? Yes ? No If yes, type:______ Route: Frequency:______ realize last used:______/______/______ ? High blood pressure ?...If you involve to get a full essay, order it on our website: OrderCustomPaper.com

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