SOLVED423

PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Madonna Miller PHYSICIAN: Alma Naraquist, M.D. SUBJECTIVE: She is still having a great deal of pain with movement. She just learned recently that her husband has prostate cancer and decisions are pending regarding treatment. OBJECTIVE: TEMPERATURE: 36.4. BLOOD PRESSURE: 112/40. PULSE: 87. RESPIRATIONS: 18. 02 SATS: 96%. Generally, appears fairly comfortable. CHEST: Clear to auscultation. No rales, rhonchi, or wheezing. HEART: Regular rate and rhythm. Bone scan shows fractures of her pelvis in the right superior and inferior pubis rami. ASSESSMENT: 1. Atraumatic pelvic fracture. 2. Severe persistent right groin pain secondary to #1. 3. Diabetes mellitus, type II. 4. End-stage renal disease, on dialysis 4. Coronary artery disease. 5. Peripheral vascular disease. PLAN: Consultation with Dr. Almaz, orthopedic surgeon, who has previously seen Madonna. She will need to be limited in her mobility for probably 6-8 weeks using either a walker or crutches. We are tentatively planning on transfer to a nursing home within the next couple of days. We will have PT and OT work with her. We will need to educate the nursing home staff about her peritoneal dialysis. We will see about getting some oral pain meds for her. We
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NURSING

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