Emma Parker Case
DISCHARGE SUMMARY
Patient name: Emma Parker
Hospial No: 11259
Admitted: 09/25/13
Discharged: 10/01/13
Consultations: Carol Dodd, M.D, Orthopedics Saul Thompson, M.D., Cardiology
Procedure: Open reduction, internal fixation of right hip.
Complication: Elevated cardiac enzymes postop.
Admitting Diagnosis: Acute intertrochanteric fracture of right hip.
ENTERING STATEMENT: This 69-year-old black female patient was brought to the ER after she sustain an injury to her right hip. She states she was walking when her right leg “gave out.’’ She fell onto the right hip. She complained of mild pain in the right hip and there was mild pain in the right hip and there was mild edema noted in the ER. In addition, she had …show more content…
Patient tolerated the procedure well under endotracheal anesthesia and was in stable condition postoperatively. She was continued on lactated Ringer’s postoperatively, and Accu-Chek was used to monitor blood sugar q.i.d. Ancef 1 g IVPB was administered x 6 doses. Diet was advanced to a 1200-calorie ADA postoperatively, and Micronase 5 mg p.o.q.d. was started on September …show more content…
Social services were requested fro help with discharge planning. The patient and her husband are both elderly, and it was felt that prior to surgery she had been helping can care for her husband and could no longer do this; therefore, nursing hom placement was suggested. The family concurred with this, and she was dischared to Purdue in stable and improved condition.
DIAGNOSTIC LAB STUDIES: Urinalysis showed 4+ rods ( not a clean catch specimen).Preop RRR were 13.8 and 30.2. Blood type O, Rh positive. Admission blood glucose was 307 and creatinine was 12. Pestop H&H were 11.8 and 34.1. Transfusion was not necessary.
FINAL DISPOSITION: Transferred to Purdue Nursing Home, where she will be continued on Mieoonse.10 mg q.d.a.m., a 1200-calorie ADA iet, Nitro-Dur 0.2 mg p.r.n. h.s., and Wygesic 1 q. 4 h.p.r.n. Ambulate with walker. Minimal weightbearing with ambulation, right lower extremity. She will be followed in the nursing home by Dr. Dodd and Dr. Thmpson and myself within one month of dichare or earlier should there be further problems. Echocardiogram was performed showing no significant abnormalities.
DISCHARGE DIAGNOSIS: 1. Acute intertrochanteric fracture of right
Patient name: Emma Parker
Hospial No: 11259
Admitted: 09/25/13
Discharged: 10/01/13
Consultations: Carol Dodd, M.D, Orthopedics Saul Thompson, M.D., Cardiology
Procedure: Open reduction, internal fixation of right hip.
Complication: Elevated cardiac enzymes postop.
Admitting Diagnosis: Acute intertrochanteric fracture of right hip.
ENTERING STATEMENT: This 69-year-old black female patient was brought to the ER after she sustain an injury to her right hip. She states she was walking when her right leg “gave out.’’ She fell onto the right hip. She complained of mild pain in the right hip and there was mild pain in the right hip and there was mild edema noted in the ER. In addition, she had …show more content…
Patient tolerated the procedure well under endotracheal anesthesia and was in stable condition postoperatively. She was continued on lactated Ringer’s postoperatively, and Accu-Chek was used to monitor blood sugar q.i.d. Ancef 1 g IVPB was administered x 6 doses. Diet was advanced to a 1200-calorie ADA postoperatively, and Micronase 5 mg p.o.q.d. was started on September …show more content…
Social services were requested fro help with discharge planning. The patient and her husband are both elderly, and it was felt that prior to surgery she had been helping can care for her husband and could no longer do this; therefore, nursing hom placement was suggested. The family concurred with this, and she was dischared to Purdue in stable and improved condition.
DIAGNOSTIC LAB STUDIES: Urinalysis showed 4+ rods ( not a clean catch specimen).Preop RRR were 13.8 and 30.2. Blood type O, Rh positive. Admission blood glucose was 307 and creatinine was 12. Pestop H&H were 11.8 and 34.1. Transfusion was not necessary.
FINAL DISPOSITION: Transferred to Purdue Nursing Home, where she will be continued on Mieoonse.10 mg q.d.a.m., a 1200-calorie ADA iet, Nitro-Dur 0.2 mg p.r.n. h.s., and Wygesic 1 q. 4 h.p.r.n. Ambulate with walker. Minimal weightbearing with ambulation, right lower extremity. She will be followed in the nursing home by Dr. Dodd and Dr. Thmpson and myself within one month of dichare or earlier should there be further problems. Echocardiogram was performed showing no significant abnormalities.
DISCHARGE DIAGNOSIS: 1. Acute intertrochanteric fracture of right