health & medical report and need an explanation and answer to help me learn. Read the instructions associated with the form for adverse reactions. You will note that the form indi
health & medical report and need an explanation and answer to help me learn.
Read the instructions associated with the form for adverse reactions. You will note that the form indicates that the patient had an adverse reaction to a drug.
Your job is to review the health record document, determine, and report the adverse reaction. Pay close attention to what is required of D1 & D4. Put your name in textbox “G” as the reporter.
DISCHARGE SUMMARY
PATEL, SHERRY #0267852
DATE OF
ADMISSION: 02/26/XX DATE OF DISCHARGE: 03/01/XX
FINAL DIAGNOSES:
1. Left femoral neck fracture
2. Paroxysmal Atrial Fibrillation, converted
to sinus rhythm
3. Urinary tract infection
4. Rash due to Bactrim
5. Mild Dementia
6. Hypertensive Heart Disease with
hypercholestrolemia
7. History of Strokes (Cerebrovascular
Accidents [CVA])
Justification of Admission
This 77-year-old female presented to the ER after falling at her beach
home. Upon examination, the patient complains of inability to walk and severe
hip pain. Her past medical history reveals multiple strokes with dementia
residuals and heart disease. X-rays revealed a femoral neck fracture. Patient
current medications include Coumadin, Diovan, OsCal, Magnesium chloride,
Megace, Levothroid, Remeron, and Lipitor.
Hospital Course
The patient was admitted and Dr. Black an Orthopedic surgeon was consulted.
On the evening of 02/26, an open reduction and internal fixation repair was
performed on the left hip. During the surgery there was a great deal of blood
loss that was replaced with three units of packed cells. The patient transfused
two units packed cells without incidence. Coumadin was placed on hold and the
patient was placed on Lasix.
Postoperatively the patient developed an atrial fibrillation which was controlled
with Toprol, Digoxin, and Verapamil. Three days postoperatively, the patient
begin to spike fevers of 101 ̊. Cultures were taken of the blood and urine. The
patient developed a urinary tract infection growing over 100,000 colonies of E.
Coli bacteria. The patient was started on Bactrim p.o. however the patient
complained of a rash over her mid-abdomen. Calamine lotion was applied to the
rash using cotton swabs. The medication was switched to Keflex. The patient is
afebrile and currently receiving physical therapy. She will be transferred to
Miami Dade College Rehab Center where she will continue her therapy.
Discharge Medications
The patient will be discharged to rehab with Lactulose 60 mg p.r.n. q.h.s.,
Darvocet 1 tablet q..6h p.r.n., Lovothroid 0.075 mg q.d., Lipitor 10 mg q.d.,
Remeron 15 md q.hs., OsCal 500+D 1 t.i.d., Coumadin 3 mg q.d., Diovan 160
mg q.d., Magnesium chloride 400-1 t.i.d., Neutra-Phos 1 tab q.i.d., Megace 100
mg q.i.d., Toprol 50-mg q.d.
Mark J. Curry, MD__ Mark J. Curry, MD
Attending Physician
Requirements: 000
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
