Case Study

  ADMISSION DATABASE Name: Juan Perez DOB: 3/22 (age 29) Physician: Deborah Kuhls, MD get it on # D ingest: TIME: TRIAGE STATUS (ER ONLY): 5 ? 7/1 ? 0730 ? Red ? Yellow ? Green ? egg white Initial alert Signs TEMP: RESP: SAO 2 : 39 ? 22 HT (in): WT (lb): B/P: PULSE: 5 ? 10 ? ? 225 ? cxv/65 ? 90 go TETANUS LAST ATE LAST DRANK unknown unknown ? unknown oral land up COMPLAINT/HX OF PRESENT ILLNESS unresponsive ALLERGIES: Meds, Food, IVP Dye, Seafood: font of Reaction unknown PREVIOUS HOSPITALIZATIONS/SURGERIES unknown first individual TO CONTACT: Name: N/A Home #: race around #: ORIENTATION TO UNIT: ? C all light ? tv/telephone ? Bathroom ? Visiting ? Smoking ? Meals ? persevering rights/responsibilities opposite ARTICLES: (Check if retained/describe) ? Contacts ? R ? L ? Dentures ? Upper ? Lower ? jewellery: necklace ? Other: ? VALUABLES ENVELOPE: ? ? Valuables instructions INFOR MATION OBTAINED FROM: ? Patient ? preceding record ? Family ? Responsible party Signature Home medicaments (including OTC) autographs: A ? Sent homeB ? Sent to pharmacyC ? Not brought in Medication dosage 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 bill ? Cold in past two weeks ? Hay febrility ? Emphysema/lung problems ? TB disorder/positive TB unclothe test ? Cancer ? Stroke/past paralysis ? firing attack ? Angina/chest pain ? Heart problems guess SCREENING Have you had a blood transfusion? ? Yes ! ? No Do you bay window? ? Yes ? No If yes, how mevery pack(s)? Does bothone 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:______ determine last used:______/______/______ ? High blood pressure ?...If you destiny to get a full essay, order it on our website: OrderCustomPaper.com

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