Patient: SS, 58 y/o female
Full code, Fall risk, no isolation, NKDA
Primary Dx: Bacteremia, Severe Back Pain
Hx: Patient reported to ED on 11/14 complaining of sudden, severe lumbar pain radiating to R. leg above the knee.
Comorbidities: HTN, CHF, COPD, Chronic Pain, Anxiety, Bipolar Depression
GU
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Urine clear, yellow, no odor
PSYCHOSOCIAL
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Intimacy v. Isolation: patient is talkative and striving for connections with others, will to talk about all history
MS
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9/10 pain in neck
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only relief is narcotics, movement worsens and sharp pain radiates down spine/shoulders
ND3: Readiness for enhanced learning r/t pain control AEB patient verbalizing desire to learn non-pharmacological interventions
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GI
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Docusate 100mg PO BID, given at 0900
CARDIO
Normal s1 and s2, no extra heart sounds, no murmurs
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Radial and DP pulse 80, 2+ bilat.
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RESP
Deep, even, unlabored, no accessory muscle usage.
Clear on inhalation, Wheezes on exhalation in all lung fields
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SKIN
warm and dry, turgor elastic
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