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M.R Male 86y.o admitted 04/21/2022; allergies: Penecillin - Coggle Diagram
M.R Male 86y.o admitted 04/21/2022; allergies: Penecillin
Diagnosed with
Spinal Stenosis of the L3-L5
defined as
A narrowing of the vertebral canal or nerve root canals caused by encroachment of bone on the space
manifested as
back pain
managed by
Acetominophen 975mg PO Q6hrs
bilarteral leg pain
bilateral leg weakness
urinary and fecal incontinence
managed by
Mirabegron 25mg PO (urinary incontinence - overactive bladder)
Right leg radiculopathy
defined as
a pinching the a nerve in the spinal colum
causing
paresthesia in the legs
as well as creating
a foot drop
palliated by
spinal decompression
functions by
implanting a device at the site of the compressed nerves to remove pressure and elevate the compressed vertebrae off the affected nerves
osteotomy
defined as
removing or adding a wedge or slice of bone to change alignment (joint and vertebral) and to shift weight bearing, correcting deformity and relieving pain
Posterior Spinal Intrumentation and Fusion
defined as
. The spine is stabilized by creating a fusion of contiguous vertebrae with a bone graft
causing
increased pain 8/10-10/10
Managed by
Acetominophen 975mgPO q6hr
hydromorphone 1mg PO Q4hr
Hydromorphone 0,5mg breakthrough Q2hr
Pregabalin 50mg PO
excreted sloley by the kidneys
1 more item...
consulted with
Pain service
Consulted with
Traumatology
monitor for
infection
fever
erythema
purulent discharge
pain 10/10
wound swelling
Past Medical Hx
Diabetes Mellitus type 2
managed by
Metformin 500mg PO BID
Gliclazide 30mg PO
Monitor for signs of hypoglycemia
Siding Scale insulin Humulin R (>10,1 mmol glycemia)
Dislipidiemia
managed by
Irbesartan 150mg PO
Benign prostatic hyperplasia
managed by
Tamusolin 0,4 PO
Chronic kidney disease
Montior for changes in Creatinine
Coronary artery disease
can cause
causing
Increased risk of clot formation
Clopidogrel 75mg PO
monitor
New bruising
PT/PTT/INR
Excessive bleeding from surgical wound
Aspirin 80mg PO
Hypertension
can lead to
Managed by
Bisoprolol 2,5mg
Monitor BP
Atorvastatin 40mg
nifedipine 90mg
Baseline status
Confused in time
Oriented in person & place
lapse in short term memory yet able to be reoriented
possibly made worse by
possibly made worse by
consulted with
Gerintology
to manage
Discharge requirements
Pain at a manageable level
Able to ambulate with help x1-2
consulted with
Physiotherapy
Occupational therapy
Able to tolerate eating meals 2-3x/day while seated in chair
priority problem
unmanaged back pain
nursing interventions
monitor pain q2hr
Offer breakthrough if pain 7/10 <
use whiteboard to remind patient to call if pain becomes present
Try non-pharmacological interventions (i.e conversations, placement of pillows to relieve back pain, guided imagery)