CASE 1 Med‑Surg Shift Report
Age: 77
Gender: Male
Current Code Status: Full Code
Chief Complaint / Reason for Admission: Ambulatory dysfunction after fall → found to have left periprosthetic hip fracture.
Allergies: NKA
Diagnosis / Working Diagnosis:
Acute periprosthetic left hip fracture
AKI likely 2/2 dehydration
Leukocytosis (reactive vs infection)
Anemia
DM, HTN, HLD, CHF, AF, SSS
Past Medical History: Bilateral hip arthroplasty, A‑fib on Eliquis, sick sinus syndrome s/p PPM, chronic diastolic CHF, DM, HTN, HLD, BPH.
Bed Type: Med‑Surg / Tele (due to arrhythmia history)
Rhythm Type: NSR (PM/telemetry)
Neuro: A&O ×4; baseline intact. No LOC. Pain present r/t fracture. Fall risk.
Respiratory: Lungs clear; RA; no SOB or increased WOB.
Cardiovascular: HR controlled; BP stable. Hx CHF/AF/PPM. Pulses intact.
GI: NPO. Abd soft, BS present. No N/V.
GU: Voiding; monitoring due to AKI. Urine studies pending.
Skin/Wounds: No acute wounds. High fall risk; monitor for breakdown.
Musculoskeletal / Mobility: Severely limited mobility due to fracture. Requires full assist.
Vitals: q4h Hemodynamically stable.
Lines / Access: PIV ×1, site CDI.
Diet: NPO for possible OR.
Accu‑Checks: Yes — q6h while NPO; ISS held.
Pain Management: Tylenol + gabapentin; monitoring response.
Orders & Follow‑Ups:
Ortho consult AM
Cardiology consult AM for clearance
PT/OT
Iron studies, ferritin
Urine studies
XR formal reads
IVF LR @ 50 mL/hr
VTE Prophylaxis: SCDs only Eliquis held
Discharge Plan: Not medically ready. Requires ortho plan & mobility evaluation.
Additional Notes / Concerns: Monitor fluid balance closely due to CHF + AKI. Safety precautions.
CASE 2: Med‑Surg Shift Report
Age: 70
Gender: Male
Current Code Status: Full Code
Chief Complaint / Reason for Admission:
Suprapubic catheter dysfunction- catheter not draining; urine via urethra.
Allergies: None reported.
Diagnosis / Working Diagnosis: SPC malfunction / obstruction
Past Medical History: Morbid obesity, lymphedema, chronic venous ulcers, SVT s/p ablation, varicose veins, BPH, chronic back pain.
Bed Type: Med‑Surg
Rhythm Type: NSR
Neuro:A&O ×4. No pain or acute changes.
Respiratory: Clear, RA, no distress.
Cardiovascular: HR 99; BP stable. No edema beyond baseline lymphedema.
GI:Abd soft, nondistended. Regular diet tolerated.
GU:SPC not draining; urine from urethra. No dysuria or fever.
Skin/Wounds: Chronic LE skin changes from venous disease; intact.
Musculoskeletal / Mobility: Baseline limited due to habitus; ambulates short distances.
Vitals: q4h
Lines / Access: PIV ×1
Diet: Regular
Accu‑Checks: No
Pain Management: Percocet PRN
Orders & Follow‑Ups:
Urology & IR consult for catheter replacement
Monitor for infection signs
Continue observation only
VTE Prophylaxis: Lovenox
Discharge Plan: Return to rehab once the catheter is functional.
Additional Notes / Concerns: High BMI makes catheter access difficult; monitor for retention.
CASE 3 Med‑Surg Shift Report
Age: 83
Gender: Male
Current Code Status: Full Code
Chief Complaint / Reason for Admission: Shortness of breath → CHF exacerbation + severe hyponatremia (Na 121).
Allergies: Amoxicillin, Penicillins, Ramipril.
Diagnosis / Working Diagnosis: Acute on chronic systolic CHF exacerbation, Hypervolemic hyponatremia
Past Medical History: CHF, CAD, AF, HTN, HLD, DM2, CKD4, BPH.
Bed Type: Med‑Surg / Telemetry
Rhythm Type: NSR with 1° AV block
Neuro: A&O ×4
Respiratory: RA
Cardiovascular: Elevated BP; baseline CHF. Bilateral LE edema.
GI: Soft abdomen; regular diet ordered (heart healthy). No N/V.
GU: Cr 2.0 (baseline CKD4). Poor UOP initially; monitor output post‑diuresis.
Skin/Wounds: Skin intact; chronic stasis changes.
Musculoskeletal / Mobility: Ambulates with assistance; edema impacts mobility.
Vitals: q4h with BMP q4h after urination.
Lines / Access: PIV x1 left 20G
Diet: Heart Healthy
Accu‑Checks: Yes- ACHS (Lantus + SSI)
Pain Management: No active pain
Orders & Follow‑Ups:
Lasix 20 mg IV
BMP q4h: 8am, 12pm and 4 pm BNP needed.
Telemetry
Hold metoprolol & amlodipine
Daily weights, strict I/O
Glucose management
VTE Prophylaxis: Heparin
Discharge Plan: Needs electrolyte stabilization; not ready for discharge.
Additional Notes / Concerns: Monitor sodium closely to prevent rapid correction.
CASE 4 Med‑Surg Shift Report
Age: 82
Gender: Female
Current Code Status: Full Code
Chief Complaint / Reason for Admission: Presyncope with dizziness, vision changes, fall.
Allergies: Doxycycline, iodine/contrast, ketorolac, naproxen, risperidone.
Diagnosis / Working Diagnosis:
Presyncope
Sinus bradycardia
Anemia
Hx autoimmune disease (MCTD, sarcoid)
Past Medical History: Anxiety, HTN, IBS, autoimmune disease, OA, glaucoma, sarcoidosis.
Bed Type: Med‑Surg / Telemetry
Rhythm Type: Sinus bradycardia
Neuro: A&O ×4; dizziness improved. No focal deficits.
Respiratory: RA.
Cardiovascular: Bradycardic; BP elevated. No chest pain.
Tele:
GI: Regular diet; no GI symptoms.
GU: Voiding independently.
Skin/Wounds: No skin breakdown; chronic knee swelling.
Musculoskeletal / Mobility: Unsteady gait; PT ordered; fall risk high.
Vitals: q4h
Lines / Access: PIV x1 left AC 18G
Diet: Regular
Accu‑Checks: ACHS
Pain Management: Reports mild pain from fall; PRN Tylenol as needed.
Orders & Follow‑Ups:
Telemetry
PT eval
Continue buspirone, fluoxetine
Continue amlodipine, metoprolol, losartan
VTE Prophylaxis: Lovenox
Discharge Plan: Pending PT safety assessment.
Additional Notes / Concerns: Monitor for recurrent dizziness; orthostatic recommended.
CASE 5 Med‑Surg Shift Report
Age: 60
Gender: Male
Current Code Status: Full Code
Chief Complaint / Reason for Admission: Severe bilateral foot pain → inability to walk.
Allergies: None known.
Diagnosis / Working Diagnosis:
Bilateral foot infection
Concern for cellulitis vs frostbite vs ischemia
Necrotic toe lesions
Leukocytosis 16.97
Past Medical History: No major PMH; ex‑smoker.
Bed Type: Med‑Surg
Rhythm Type: NSR
Neuro: A&O ×4; severe foot pain.
Respiratory: RA.
Cardiovascular: Tachycardia resolved. Pulses present via Doppler.
GI: Regular diet.
GU: Voiding normally.
Skin/Wounds:
Bilateral foot erythema
Dusky discoloration
Green patches
Black eschar on R great & 2nd toe
Edema R +1, L +2
Musculoskeletal / Mobility: Unable to ambulate; bedbound due to pain.
Vitals: q4h
Lines / Access: PIV x1 LAC 20G
Diet: Regular
Accu‑Checks: No
Pain Management: PRN analgesics; monitor effectiveness.
Orders & Follow‑Ups:
Continue Unasyn IV
Foot X‑ray
ESR, CRP, CK
Podiatry consult
Wound Care consult
ID consult
Consider Vascular
VTE Prophylaxis: Lovenox
Discharge Plan: Not medically ready. Requires wound assessment & infection control.
Additional Notes / Concerns: High concern for ischemic changes; monitor perfusion closely.
Note: Potassium replacement x2 bags
No comments:
Post a Comment