Student’s Name: Morgan Whitmore Unit:DT8 Date: 4-5-2011
History/Physical and
Summary of Hospitalization
Init. RMcC Age 72 years old Gender male Rm. # 65-2 Ethnicity Caucasian Admit Date 4-1-2011
Admitting Diagnosis Chemotherapy for recurrent Primary CNS lymphoma.
Past Medical History (This should include information on any other medical problems the pt. may have such as heart disease, diabetes, HTN, etc. as identified in physician's H&P, progress, consultations and medications.) Patient has a history of benign paroxysmal positional vertigo, bilateral sensorineural hearing loss, lymphoma of central nervous system, removal of prostate, pulmonary embolism, and craniotomy tumor.
History of Current Illness/Injury (What precipitated this hospitalization): Patient had last round of chemotherapy 3/11-3-18. He is back for his continuation of chemotherapy treatment to treat his recurring CNS lymphoma.
Vital Sign Trends for Previous 24 hours: T max. 36.3-36.5 P 6-71 R 14-18 BP 132/80-160/90 O2 Sat 95-97
Intake last 24/hrs 6,023.5 mL Output last 24/hrs 4,475 mL Wt today 70.7 Kg; Wt yesterdays 70.7 Admit wt 70.217 Kg,
Braden scale score 21; Fall risk score 35
Abnormal Physical Assessment findings: (Use Prep day data) Patient was very nauseated and vomited frequently.
Nursing Care:
Activity: as desired Nutrition/Route: regular diet
DVT Prophylaxis: continuous alternating leg pressure devices Type of IV / IV solution: NS 0.9% 20 mL/hour continuous
Pulmonary Care/Airway: pulse oximetry with vital signs Code Status: Full Code
Tubes/Drains: None Allergies: Dilantin/Phenytonin Sodium, Contrast Dye, Heparin Agents
Wound Care: None Special Precautions: None
Misc: Vital signs...