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Published by admin, 2018-01-12 15:29:34

Final Exam Part II: Medical Chart

Final Exam 2 Patient Charting

MEDICAL CHART

Confidential
SKY NURSES HOSPITAL 6530 W. Rogers Circle, Suite 31, Boca Raton, FL 33487

Contents

Emergency Room............................................................................................................................................................. 2
Initial Trauma H&P / James Thomas O’Neill, DO ........................................................................................................... 2

Admission, History & Physical .......................................................................................................................................... 4
Progress Notes................................................................................................................................................................. 6
Nursing Notes .................................................................................................................................................................. 8
Medication ...................................................................................................................................................................... 9
Vital Signs .......................................................................................................................................................................11
Weight............................................................................................................................................................................11
Lab Reports.....................................................................................................................................................................12
X-Ray, MRI, CT ................................................................................................................................................................15
Consultations ..................................................................................................................................................................16
Anesthesia ......................................................................................................................................................................17
Operative Path................................................................................................................................................................19
Discharge........................................................................................................................................................................20

NOTE: This contents of this medical chart is to be used to answer the questions presented on the Final Exam Part II.

Emergency Room

Initial Trauma H&P / James Thomas O’Neill, DO

Date: 12/07/2017

Time: 14:35

Mr. Zhao is a 49-year-old man who was a crew member aboard the vessel, JIA MAO SHAN. On 12/07/2017, Mr. Zhao fell
from a ladder (approximately 3-5 meters per medical documentation) striking a bulkhead. He was non-ambulatory after
the event. He was taken off the ship by the United States Coast Guard and placed into an ambulance. He was transported
to the University of Maryland Medical Center.

Mr. Zhao denied loss of consciousness (LOC) after the fall. Upon arrival into ER Trauma, it was noted that he was
complaining of pain in his right leg around the lateral thigh and knee. X-ray of the right leg revealed an acute comminuted
displaced fracture of the proximal femoral shaft with radial displacement of the main distal fragment. A 20-lb weight was
placed prior to surgery.

Chief Complaint: Right Leg Pain

Surgical –

Patient denies surgical history.

Medical History –

Patient denies medical history.

Allergy: No Known Drug Allergies

Social History –

Alcohol use: None

Tobacco use: None

Medication: No prescription or illegal drug use. Occasional OTC ibuprofen for headache.

Family History

Mother: 79, alive and well. Lives in Beijing China

Father: 54, deceased, lung cancer. Father worked in the coal mining industry. No brothers or sisters.

Review of Systems

Neuro: He is alert and oriented to person, place, and time. No cranial nerve deficit. GCS eyes subscore is 4. GCS verbal
subscore is 5. GCS motor subscore is 6.

Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. Cervical collar
and backboard in place.

Mandarin Chinese Speaking

Physical Exam

Date Temperature Pulse Respiration Blood Oxygen Saturation Pain
12/07/2017 37.1 °C (98.8°F) 88 20 Pressure 99% Level
114/60

HEENT:
Head: Normocephalic and atraumatic
Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light. No scleral icterus.
Neck: Normal range of motion. Neck supple. No JVD present. No tracheal deviation present.
Cardiovascular: Regular rhythm, normal heart sounds S1, S2 and intact distal pulses.
Pulmonary/Chest: Effort normal. No respiratory distress. No respiratory support.
Abdominal: soft. He exhibits no distension. There is no tenderness. There is no rebound.
Musculoskeletal: Right thigh closed deformity.
Skin: Skin is warm and dry. No rash noted. He is not diaphoretic. No pallor.
Psychiatric: He has a normal mood and affect. His behavior is normal.

Admission, History & Physical

Attending: Laura Susan Buchanan, MD

Date of Admission: 12/07/2017

Date: 12/08/2017

History of Present Illness

Patient Name: Chang Zhao

Date of Birth: 02/28/1968

Referral Source: Emergency Department

Data Source: Patient

Chief complaint & ID: Right Femoral Shaft Fracture

History of Present Illness

This is the first admission for this 49-year-old crew member who was aboard the vessel, HUANG CHO MI.

Mr. Zhao is a 49-year-old man who was a crew member aboard the vessel, HUANG CHO MI. On 12/07/2017, Mr. Zhao fell
approximately 3-5 meters from a ladder. He denied LOC after the fall. During his fall, Mr. Zhao sustained an injury to his
right leg. He was taken off the ship and transported to the University of Maryland Medical Center.

Past Medical History

Surgical –

1976: Appendectomy

Medical History –

None

Allergy: Penicillin; experienced rash and hives in 1976.

Social History –

Alcohol use: None

Tobacco use: None

Medication: No prescription or illegal drug use. Occasional OTC ibuprofen for headache.

Family History

Mother: 79, alive and well. Lives in Beijing China

Father: 54, deceased, lung cancer. Father worked in the coal mining industry. No brothers or sisters.

Review of Systems

Neuro: He is alert and oriented to person, place, and time. No cranial nerve deficit. GCS eyes subscore is 4. GCS verbal
subscore is 5. GCS motor subscore is 6.

Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. No distress.

Mandarin Chinese Speaking

HEENT:
Head: Normocephalic and atraumatic
Eyes: Conjunctivae are normal. Pupils are equal, round, and reactive to light. No scleral icterus.
Neck: Normal range of motion. Neck supple. No JVD present. No tracheal deviation present.
Cardiovascular: Regular rhythm, normal heart sounds S1, S2 and intact distal pulses. Tachycardia present. Exam reveals
no gallop and no friction rub. No murmur heard.
Pulmonary/Chest: Effort normal. No respiratory distress. He has no wheezes. No respiratory support.
Abdominal: soft. He exhibits no distension. There is no tenderness. There is no rebound.
Genitourinary: Foley in place, scrotal edema and hematoma.
Musculoskeletal: He exhibits tenderness (R hip). RLE dressings c/d/I, incision c/d/I, NV intact, compartments soft, could
not flex or extend R hip or R knee
Skin: Skin is warm and dry. No rash noted. He is not diaphoretic. No erythema. No pallor.
Psychiatric: He has a normal mood and affect. His behavior is normal.

Progress Notes

Date Time Service Provider Notes
Sandra L Russell, RN
12/15/2017 14:40 Discharge paperwork completed.
12/15/2017 08:12 Patient did not leave as scheduled as their was
confusion on who was to take the patient to the hotel.
12/15/2017 08:00 Kristen Barron, PT The security officer that was with the patient did not
12/15/2017 07:08 Brian S Myer, MD seem to know what was going on per the nurse. The
12/14/2017 16:23 Meghan Robben, PT security guard stated at 11:30 PM that he would take
12/14/2017 12:47 Eileen Teunis, OT him. Nurse refused to allow him to be transported at
12/14/2017 11:11 Sandra Russell, RN that hour due to inconsistency by security officer.
Begin: 08:15 – End: 08:53
12/13/2017 16:06 Rachel Kotzker, PT RLE dressing c/d/I, tenderness to right hip
12/13/2017 14:07 Sandra Russell, RN Begin: 11:25 – End: 11:50
Begin Time: 12:47 – End Time: 13:19
12/13/2017 11:45 Rachel E Brownback, OT Case management – Tara Rose, RN, Sky Nurses Case
12/13/2017 09:29 Sean E Slaven, MD Management. Hemoglobin has dropped to 8.0 from
8.4.
12/13/2017 09:20 Rachel Kotzker, PT Begin: 15:30 – End: 1540
12/13/2017 07:45 Fornati Bedell, MD Case Management – Tara Rose, RN, Sky Nurses Case
Management
12/13/2017 06:49 Brian S Myer, MD Begin Time: 11:45 – End Time: 12:15
12/12/2017 17:48 Sandra Russell, RN Shock Trauma Orthopaedic Progress Notes:

12/12/2017 15:10 Rachel Shulder, PT • Dry dressing changes as needed
12/12/2017 10:58 Rachel Shulder, PT • WBAT RLE
12/12/2017 07:01 Brian S Myer, MD • PT/OT
12/12/2017 06:01 Sean E Slaven, MD • DVT ppx per primary team; if flying back to

12/11/2017 16:07 Darlene R. Gray, RN China would recommend appropriate DVT
ppx for high risk prolonged flight
12/11/2017 13:04 Lauren E. Tigani, PT Begin: 09:20 – End: 09:58
12/11/2017 09:16 Lauren E. Tigani, PT Urology Consult – scrotal ultrasound showed no injury
12/11/2017 08:49 Sean E Slaven, MD ad hematoma and edema. Foley catheter in place
draining clear urine.
Trauma Team Daily Progress Note
Case Management – Urology consult pending. Tara
Rose, RN, Sky Nurses Case Management
Begin: 15:10 – End: 15:18
Begin: 08:26 – End: 09:00

Shock Trauma Orthopaedic Progress Notes: Patient is
doing well postoperatively. Pain is well controlled.
Continues working with PT. Blisters decompressed
and dressed at bedside yesterday.
Case Management – Tara Rose, RN, Sky Nurses Case
Management
Begin: 13:04 – End: 13:25
Begin: 08:14 – End: 08:56
Shock Trauma Orthopaedic Progress Notes: Patient is
doing well postoperatively. Pain is well controlled.
DVT US yesterday, negative for VTE.

12/11/2017 07:00 Brian S. Myer, MD Exhibits edema to the right leg and tenderness in the
right hip. RLE dressing c/d/i/, incision c/d/I,
12/10/2017 17:23 Deborah A. Green, RN compartments soft.
12/10/2017 13:59 Meghan Robben, PT
12/10/2017 11:35 Meghan Robben, PT Foley catheter in place.
12/10/2017 08:12 Nicolas M. Hernandez, MD Case Manager – Tara Rose, RN, Sky Nurses Case
12/09/2017 16:57 Debra A. Green, RN Management
12/09/2017 16:50 Meghan Robben, PT Begin: 13:59 – End: 14:26
12/09/2017 13:41 Meghan Robben, PT Therapy on hold until ultrasound
Shock Trauma Orthopaedic Progress Note: Mild
12/09/2017 07:46 Benjamin M. Wheatley, MD swelling right thigh, evaluate with DVT ultrasound.
Case Manager – Tara Rose, RN, Sky Nurses Case
12/09/2017 06:24 Jose Jesus Diaz Jr., MD Management
12/08/2017 17:38 James Thomas O’Neill, DO Begin: 15:07 – End: 15:31
Begin: 08:55 – End: 0937
12/08/2017 16:00 Sandra Russell, RN
12/08/2017 15:08 Justin A. Perry, LGSW Treatment: 2x per day
12/08/2017 0653 Laura Susan Buchanan, MD Shock Trauma Orthopaedic follow-up: Patient is doing
12/08/2017 06:30 Curtis Charles Copeland, MD well postoperatively.
12/07/2017 20:25 Laura Susan Buchanan, MD
Plan:
12/07/2017 20:24 Christopher M Belyear, MD • WBAT RLE
12/07/2017 14:35 Orthopedic • PT/OT
James Thomas O’Neill, DO • DVT per primary team
• Ancef X 24 hrs

Trauma Team Daily Progress
Post-op Evaluation: Patient doing well post-
operatively, complaining only of nausea and swelling
in his surgically repaired leg. He is eager to begin
moving and returning to work as soon as possible.

Ext: right leg s/p IMN, appropriate peri-incisional
tenderness with nonpitting edema, neurovascularly
intact
Assigned Case Manager – Trauma
Social Worker Consult
Pre-op assessment
Anesthesiology Pre-Anesthetic Evaluation
History and physical completed. No change noted
from previous H&P completed by James Thomas
O’Neill, DO.
Shock Trauma Orthopaedic Consult

History and physical completed. See history and
physical.

Nursing Notes

Date Time Clinician Notes
12/14/2017 22:33 Sunny H Oh, RN Patient refused to talk to nurse. Ask her to leave his room.
12/13/2017 22:45 Danielle Hart, RN New order to remove Foley. Follow catheter removal protocol.
Informed by Tara Rose, RN (Sky Nurses) that patient’s
12/13/2017 hemoglobin needed to be at least 9 for the flight. Will draw
H&H in the AM. Tara Rose, RN will call back at 05:00 on
12/12/2017 12/14/2017.
12/11/2017
12/11/2017 Patient returned demonstration on self-administration of
12/10/2017
12/09/2017 Lovenox injection.
12/09/2017
12/09/2017 08:30 Stephanie Witt, RN Foley care and UTI prevention explained to patient. Patient was
12/08/2017
12/08/2017 able to demonstrate proper Foley care. Explained how to give
12/08/2017
12/08/2017 the anticoagulant injection. No return demonstration noted.
12/07/2017
Mesh undergarments applied for compression, elevated
12/07/2017
12/07/2017 scrotum on towel and heat pack applied.

12/07/2017 08:00 Mary Dailey, RN Patient reports pain as tolerable at a 5/10.

12/07/2017 2045 Jennifer Montgomery, Foley inserted.

RN

14:43 / Faythe Benny, RN Per patient bladder feels full, penis is more painful and he is

18:35 unable to urinate. Genitals are more edematous.

04:30 Courtney Clavelle, RN Patients H&H dropped to 6.9 and 20.8. 1 unit of PRBC’s given.

06:30 Rachel Palmer, RN Bladder scan showed 315mL.

05:00 Rachel Palmer, RN Bladder scan showed 315mL.

02:30 Rachel Palmer, RN Bladder scan showed 240mL.

20:00 Rachel Palmer, RN Bladder scan showed 575mL. Patient straight cath per order

(650mL) amber output. Encourage to increase PO intake.

18:30 Faythe Benny, RN MD encourage PO intake and bladder scan at 22:00.

18:24 Faythe Benny, RN Bladder scan for 270cc/hr. Called physician.

16:00 Faythe Benny, RN Patient due to void (6 hours post cath removal). Bladder

scanned patient for 90cc, will reassess in 2 hours.

2200 Rachel Palmer, RN Patient oriented to room and unit by use of interpreter. Agent

at bedside. Patient resting comfortably, no other interventions

at this time.

2030 Tracy Newhouse, RN Patient to be admitted

18:35 Lauren Westbrook, RN 20 lbs. right femoral traction placed by Chris from ortho team.

Following traction placement, patient’s right thigh noted to be

stiff and tight, with limited compression. Ortho at bedside to

evaluate, no new orders at this time. Right pedal pulse +2, right

posterior tibial pulse +1. Will continue to monitor closely.

14:05 Lauren Westbrook, RN Pt speaks only Mandarin Chinese; presents alert, oriented via

translation, and appropriate. Updates, plan of care, education

and emotional support provided via translation line.

14:03 Amy Caldwell, RN Patient admitted to TRU 7 S/P fall from ladder on freighter.

Prolonged extrication. Patient attached to monitors. Trauma

assessment completed. Await labs, X-rays, and CT scans for

plan.

Medication Dosage Time

12/15/2017 5mg 3X daily
0.4mg 1X daily QPM
Medication – No change 17 g 1X daily
100mg 2X daily
12/14/2017 30mg 2X daily
5mg Q3H
Medications – No Change 1 tablet 2X daily

12/13/2017 Dosage Time
650mg Q4H PRN
Medications – No change 0.5mg Q3 min PRN
0.4mg Q2H PRN
12/12/2017 4mg Q4H PRN
5mg Q3H PRN
Medications – No change
125cc/hr Continuous
12/10/2017

Medication
Scheduled Medications
Baclofen
Tamsulosin
Polyethylene glycol
Docusate sodium
Enoxaparin
Oxycodone
Senna
PRN Medications
Medication
Acetaminophen
Atropine
HYDROmorphone
Ondasetron
oxycodone
Intravenous
Dextrose 5%-0.45% NS with KCL 20mEq

12/09/2017 Dosage Time

Medication 2g Q8H
Scheduled Medications 5mg 3X daily
ceFAZolin 100mg 2X daily
Baclofen 5,000 units 3X daily
Docusate sodium 5mg Q3H
Heparin 1 tablet 2X daily
Oxycodone
Senna Dosage Time
PRN Medications 650mg Q4H PRN
Medication 0.5mg Q3 min PRN
Acetaminophen 0.4mg Q2H PRN
Atropine 4mg Q4H PRN
HYDROmorphone 5mg Q3H PRN
Ondasetron
oxycodone 125cc/hr Continuous
Intravenous
Dextrose 5%-0.45% NS with KCL 20mEq Time

12/08/2017 Dosage 3X daily
2X daily
Medication 5mg 3X daily
Scheduled Medications 100mg Q3H
Baclofen 5,000 units 2X daily
Docusate sodium 5mg
Heparin 1 tablet Time
Oxycodone Q4H PRN
Senna Dosage Q3 min PRN
PRN Medications 650mg Q2H PRN
Medication 0.5mg Q4H PRN
Acetaminophen 0.4mg Q3H PRN
Atropine 4mg
HYDROmorphone 5mg Continuous
Ondasetron
oxycodone 125cc/hr
Intravenous
Dextrose 5%-0.45% NS with KCL 20mEq

Vital Signs

Date Time Temperature Pulse Respiration Blood Oxygen Saturation
Pressure
12/15/2017 07:08 36.6° C (97.9°F) 102 20 106/62 98%
12/14/2017 07:12 36.7° C (98.1°F) 96 16 125/59 98%
12/13/2017 07:37 36.5° C (97.7°F) 114 20 123/66 97%
12/12/2017 04:44 37.3° C (99.1°F) 84 13 121/66 96%
12/11/2017 08:06 36.9° C (98.4°F) 107 18 115/65 98%
12/10/2017 07:57 36.3°C (97.3°F) 132 23 124/59 100%
12/09/2017 06:24 36.1°C (97.0°F) 110 20 124/76 98%
12/09/2017 03:10 36.5 °C (97.7°F) 110 20 124/76 98%
12/08/2017 17:38 36.1°C (97.0°F) 89 15 113.69 100%
12/08/2017 06:53 36.4°C (97.5°F) 76 18 122/73 100%
12/07/2017 14:30 37.1 °C (98.8°F) 88 20 114/60 99%

Weight Weight

Date 55.8 kg (123 lbs.)
12/14/2017 55.8 kg (123 lbs.)
12/08/2017 55.8 kg (123 lbs.)
12/07/2017

Lab Reports Time Laboratory Value
03:53 WBC 12.6
Date 03:53 Hemoglobin 8.0
12/14/2017 03:53 Hematocrit 24.3
12/14/2017 03:53 Platelets 232
12/14/2017
12/14/2017 Time Laboratory Value
04:06 WBC 6.3
Date 04:06 Hemoglobin 7.4
12/12/2017 04:06 Hematocrit 22.3
12/12/2017 04:06 Platelets 124
12/12/2017
12/12/2017 Time Laboratory Value
18:01 Hemoglobin 7.9*
Date 18:01 Hematocrit 23.2*
12/10/2017
12/10/2017 Time Laboratory Value
03:58 WBC 8.6
Date 03:58 Hemoglobin 6.9
12/10/2017 03:58 Hematocrit 20.8
12/10/2017 03:58 Platelets 104
12/10/2017 03:58 Prealbumin 12*
12/10/2017
12/10/2017 Time Laboratory Value
06:43 WBC 10.3
Date 06:43 Hemoglobin 8.9
12/09/2017 06:43 Hematocrit 26.9
12/09/2017 06:43 Platelets 123
12/09/2017
12/09/2017 06:43 Sodium 137
06:43 Potassium 3.5
12/09/2017 06:43 Chloride 100
12/09/2017 06:43 Anion Gap 8
12/09/2017 06:43 BUN 10
12/09/2017 06:43 Creatinine 1.00
12/09/2017 06:43 Glucose BLD 103
12/09/2017
12/09/2017 03:34 PROTIME 13.8
03:24 PTT 30
12/08/2017 03:24 INR 1.0
12/08/2017
12/08/2017

Date Time Laboratory Value
12/09/2017 04:30 WBC 11.3
12/09/2017 04:30 Hemoglobin 9.5
12/09/2017 04:30 Hematocrit 28.8
12/09/2017 04:30 Platelets 150

12/09/2017 04:30 Sodium 137
12/09/2017 04:30 Potassium 3.5
12/09/2017 04:30 Chloride 100
12/09/2017 04:30 CO2 29
12/09/2017 04:30 Anion Gap 8
12/09/2017 04:30 BUN 10
12/09/2017 04:30 Creatinine 1.00
12/09/2017 04:30 Glucose BLD 103

12/09/2017 04:30 Calcium 7.9

Date Time Laboratory Value
12/08/2017 03:24 WBC 10.4
12/08/2017 03:24 Hemoglobin 13.0
12/08/2017 03:24 Hematocrit 39.1
12/08/2017 03:24 Platelets 165

12/08/2017 03:24 Sodium 143
12/08/2017 03:24 Potassium
12/08/2017 03:24 Chloride 102
12/08/2017 03:24 Anion Gap 28
12/08/2017 03:24 BUN 11
12/08/2017 03:24 Creatinine 0.84
12/08/2017 03:24 Glucose BLD 114*

12/08/2017 03:34 PROTIME 13.8
12/08/2017 03:24 PTT 30
12/08/2017 03:24 INR 1.0

Date Time Laboratory Value
12/07/2017 14:10 WBC 20.6*
12/07/2017 14:10 Hemoglobin 14.4
12/07/2017 14:10 Hematocrit 41.7
12/07//2017 14:10 Platelets 187

12/07/2017 14:10 Sodium 140
12/07/2017 14:10 Potassium 3.9
12/07/2017 14:10 Chloride 104
12/07/2017 14:10 CO2 25
12/07/2017 14:10 BUN 12
12/07/2017 14:10 Creatinine 0.83
12:07/2017 14:10 Glucose BLD 112*
12/07/2017 14:10 Anion Gap 11

12/07/2017 14:10 Calcium 8.9
12/07/2017 14:10 Magnesium 2.0
12/07/2017 14:10 Phosphorus 2.8

12/07/2017 14:10 Osmolality 294

12:07/2017 14:10 AST 35
12/07/2017 14:10 ALT 38
12/07/2017 14:10 Amylase 76
12/07/2017 14:10 Bilirubin Total 1.3*
12/07/2017 14:10 Total Protein 7.9
12/07/2017 14:10 Albumin 4.6
12/07/2017 14:10 ALK Phos 61

12/07/2017 14:10 Lactate 2.4*
12/07/2017 14:10 CK Total 231*
12/07/2017 14:10 Troponin I <0.02
12/07/2017 14:10 Myoglobin 169*

12/07/2017 14:10 PTT 26
12/07/2017 14:10 Protime 13.0
12/07/2017 14:10 INR 1.0
12/07/2017 14:10 Fibrinogen 189*

12/07/2017 15:51 PH UA 7.0
12/07/2017 15:51 Color Straw
12/07/2017 15:51 Blood UA Negative
12/07/2017 15:51 RBC UA 3-5*
12/07/2017 15:51 Glucose UR Negative
12/07/2017 15:51 Bacteria UA Negative
12/07/2017 15:51 WBC UA 0-2
12/07/2017 15:51 SQUAM EPITHEL UA Negative

X-Ray, MRI, CT

Date Exam Impression
12/12/2017 Ultrasound
US Pelvic – there is no extensive subcutaneous edema in the
12/10/2017 Ultrasound penile and adjacent scrotum region, consistent with likely
12/08/2017 Femur >=2 views Right spread of hematoma from adjacent right proximal femoral
12/07/2017 AP Supine Portable Pelvis fracture site.
Negative for VTE
12/07/2017 Right Femur 2 Views No immediate postoperative complications noted.
There is complete fracture of the proximal right femur with
12/07/2017 Right Knee 2 Views / Right Lower displacement. There are no pelvic fractures.
Leg 2 Views There is an acute comminuted displaced fracture of the
12/07/2017 CT Head/Brain W/O Contrast proximal femoral shaft with radial displacement of the
12/07/2017 CT Head/Brain W Contrast main distal fragment.
12/07/2017 Cervical Spine W Contrast No acute fracture or malalignment of the right knee or right
12/07/2017 CT thoracic Spine W Contrast lower leg.
12/07/2017 CT Lumbar Spine W Contrast No vascular injury identified.
12/07/2017 CT Abdomen/Pelvis W Contrast No vascular injury identified.
12/07/2017 X-Ray Femur >= 2 View Right No vascular injury identified.
No vascular injury identified.
No vascular injury identified.
No vascular injury identified
Right femur 2 views show an acute comminuted displaced
fracture of the proximal femoral shaft with radial
displacement of the main distal fragment. Right knee 2
views and right lower leg 2 views show no acute fracture or
malalignment of the right knee or right lower leg.

Consultations

Date: 12/13/2017
Time: 07:45
Fornati Bedell, MD
Urology
Plan: Conservative management with tight scrotal underwear, elevation and warm compression as needed. Continue
Foley catheter. Patient should follow up in urology clinic in 4 weeks to examine progress of healing.

Anesthesia

Date: 12/08/2017
Time: 06:10

Anesthesia Pre-Anesthetic Evaluation

Mr. Zhao is a 49-year-old man who was a crew member aboard the vessel, JIA MAO SHAN. On 12/07/2017, Mr. Zhao fell
from a ladder (approximately 3-5 meters per medical documentation) striking a bulkhead.
Weight: 55.8 kg (123 lb.), Height: 165 cm (5’ 4.98”)
Preoperative Diagnosis
Right Femur Fracture
Planned Surgical Procedure
OPEN REDUCTION OF FEMOAL SHAFT FRACTURE/POSSIBLE RETRO NAILING
NPO Status: >8 hrs
Surgical –

Patient denies surgical history.
Medical History –

Patient denies medical history.
Anesthesia History

Complications: No known history of anesthesia complications

Allergy: No Known Drug Allergies

Social History –

Alcohol use: None

Tobacco use: None

Medication: No prescription or illegal drug use. Occasional OTC ibuprofen for headache.

Medications

Continuous Infusion: Dextrose 5%-0.45% Sodium Chloride with KCL 20mEq

Last Rate: 125 cc/hr

Peripheral IV: 18 G Right Forearm

Inserted: 12/07/2017 @ 14:15

Medication Dosage Time
Scheduled Medications
Baclofen 5mg 3X daily
Docusate sodium 100mg 2X daily
Heparin 5,000 units 3X daily
Oxycodone 5mg Q3H
Senna 1 tablet 2X daily
PRN Medications
Medication Dosage Time
Acetaminophen 650mg Q4H PRN
Atropine 0.5mg Q3 min PRN
HYDROmorphone 0.4mg Q2H PRN
Ondasetron 4mg Q4H PRN
oxycodone 5mg Q3H PRN

Review of Systems

Neuro: He is alert and oriented to person, place, and time. No cranial nerve deficit. GCS eyes subscore is 4. GCS verbal
subscore is 5. GCS motor subscore is 6.

Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. Cervical collar
and backboard in place.

Mandarin Chinese Speaking

Physical Exam

Date Temperature Pulse Respiration Blood Oxygen Saturation Pain
12/08/2017 36.8 °C (98.2°F) 76 18 Pressure 100% Level
12/73 0/10

Date Time Laboratory Value
12/08/2017 03:24 WBC 10.4
12/08/2017 03:24 Hemoglobin 13.0
12/08/2017 03:24 Hematocrit 39.1
12/08/2017 03:24 Platelets 165

12/08/2017 03:24 Sodium 143
12/08/2017 03:24 Potassium
12/08/2017 03:24 Chloride 102
12/08/2017 03:24 Anion Gap 28
12/08/2017 03:24 BUN 11
12/08/2017 03:24 Creatinine 0.84
12/08/2017 03:24 Glucose BLD 114*

12/08/2017 03:34 PROTIME 13.8
12/08/2017 03:24 PTT 30
12/08/2017 03:24 INR 1.0

Operative Path

Date of Service: 12/08/2017
Time: 10:23
Procedure: Right femur IMN
Surgeon(s) and Role: Jason W. Nascone, MD – Primary
Anesthesia: Curtis Charles Copeland, MD
Anesthesia Type: General
Devices Implanted:

• NAIL SN 71635234 FEM ANTE 10MMX34 / SMITH & NEPHEW ORTHO / RIGHT / 1
• NAIL SN 71635234 FEM ANTE 10MMX34 / SMITH & NEPHEW ORTHO / RIGHT / 1
• SCR SN 71645035 TRIGEN 5MMX35MM / HARDWARE ORTHO / SCR SN 71645035 TRIGEN 5MMX35MM / SMITH

& NEPHEW ORTHO / RIGHT / 1
Estimated Blood Loss: less than 100 mL
Complications: None
Disposition and follow-up: hospitalization and follow

Weightbearing Status: WBAT
Anticoagulation: per primary team
Antibiotics: Ancef x 24 hours

Discharge

Discharge Summary: 12/15/2017

Patient: Chang Zhao

Age: 49 years old

DOB: 02/28/1968

Date of Admission: 12/07/2017

Attending Physician: Laura Susan Buchanan, MD

Discharging Physician: Brian Myer, MD

Reason for Admission: right proximal diaphyseal comminuted fracture

Mechanism of Injury: Fall

Admitting Diagnosis: Right proximal diaphyseal comminuted fracture

Surgical Procedures: Intramedullary nail repair of right femur

Discharge Medications

Medication Dosage Time
Acetaminophen 325mg tablet 325mg Q4H PRN
Take 2 tablets by mouth every 4 hours as
needed for MILD Pain or Fever (temp in 5mg 3X daily
PRN comment) (Fever >38.0 C) 30mg 2X daily
Commonly known as: Tylenol 5mg Q6H PRN
Baclofen 10mg tablet
Take 0.5 tablets by mouth 3 times daily. 1 capsule QHS
Commonly known as: Lioresal
Enoxaparin sodium 30mg/0.3mL injection
Inject 0.3 mls into the skin 2 times daily for
14 days
Oxycodone 5mg immediate release tablet
Take 1 tablet by mouth every 6 hours as
needed for Breakthrough Pain.
Commonly known as: Roxicodone
Tamsulosin 0.4mg capsule
Take 1 capsule by mouth every evening for
7 days.
Commonly known as: Flomax

Diet: Resume Regular diet following surgery.

Discharge Activity: As tolerated, No strenuous activity until seen in follow-up by orthopedic surgeon or after 12 weeks
from surgery.

Weightbearing Status: right Lower Extremity Weight Bearing: WBAT


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