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July 7, 2024

Age: 56 **Full code Arrive:since a week ago The problem: knee pain down to shin

General Question

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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