Age: 56 **Full code Arrive:since a week ago The problem: knee pain down to shin
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Get it written →Age: 56
**Full code
Arrive:since a week ago
The problem: knee pain down to shin
Diagnose: sptic arthritis
assistive: glasses
** he has hard of hearing
Discharge: unknown
Goals: pain control , go home
Goals for the day: monitor vitals and labs. pain control maintain weight bearing status to LLE. Maintain immobiliser.
line and wounds
Line: catheter: peripheral venous gauge left forearm .
Wounds: incision knee left post surgical site.
Wound therapy: vacuum assist closure knee left anterior
Vital Signs
Temperature: 36.3
Plus: 75
Spo2 : 95
Resp : 18
Bp : 147/83
Lab
Carbon dioxide 19 (22-29)
Sodium 129 (136-140)
Creatinine 0.70( 0.72-1.25)
Glucose 105 (70-99)
Haemoglobin 11.8 (13.50-17.50)
Calcium 7.5 (8.4-10.2)
Red cell count 3.95 (4.50-5.90)
Hematocrits 34.8 (41-53)
Pain assessment
In his left knee
Describe the pain: throbbing
Scales 0 out of 10: 0 pain when resting 7 out of 10 when standing or active 9
Medication
norco 10- 325 mg per tab 1-2 tab (every 4 hours)
Melatonin tab 3gm
Aspirin EC tab 325 mg 2 times a day
Lisinopril tab 10 mg
Milk of magnesia susp 30 ml
Lyrica 50 mg 3 times a day
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