CASE FOR OCTOBER 5, 2022 ACTIVITY

NAME:ITANI MOHAMAD MOHAMAD ITANI

HOSPITAL NUMBER:123456

MUSLIM

CASH PATIENT

Age & Gender: 94y , Male

DOB :     25-Dec-1927

RN Joseph (0327) Start Date : 04-Oct-2022 15:55 End Date : 04-Oct-2022 15:57

FOR POSSIBLE IRRIGATION AND DEBRIDEMENT

ALLERGIES:LATEX

NPO POST MIDNIGHT

CEFAZOLIN 2 GRAMS AN HOUR BEFORE SKIN INCISION

Vital Signs

04-Oct-2022 14:00 :- Pain: No, Temperature: 36.8°C Tympanic, Respiratory Rate Adult:
20Breath/min, Heart Rate Adult: 64Beats/Min, Systolic BP Adult: 149, Diastolic BP Adult: 67,
SpO2(%): 96,

Patient Position: Semi Fowlers

Numeric: No Pain (0) Assessment

Value :

Pain  :     0(0)

hief Complaint\Title: COVID 19 POSITIVE

Physician note

Physician Note

94 y o male pt

Alzheimer??

DM

HTN

Hx. of CVA 1 month ago on aspirin

complain of,fever , SOB , since 2 days , productive cough yellowish sputum , vomiting

pt. seen

conscious ,oriented , O2SAT 94% On RA , Afebrile

chest bilateral crepitation and decrease air entry

Chest X ray AP, portable view.

No evidence of definite consolidation

Both costophrenic angles appear clear.

The provided thoracic bony cage look unremarkable.

Labs: wbc 5.57 , creatinine 1.39 , trop I negative

Urine analysis : Pus cells 0-2 , RBC 30-50, CRP 77.4

ABG done ;

PH 7.42 , PCO2 31 , PO2 81 , HCO3 22.3

Entry Date:02-Oct-2022 3:27:00 PM

Chest X rayAP, portable view.

Findings:

No evidence of definite consolidation

Both costophrenic angles appear clear.

The provided thoracic bony cage look unremarkable.

Impression:

COVID 19 POSITIVE

AKI

Treatment Plan

NPO

NS 80 ml \hr

rocephin 1 g BID

tavanic 500 mg OD

regular perfalgan 1 g TID

PPI

DVT assessment

send ABG

LDH ,,ferritin AST and ALT

home medication

chest and LIMBS PT