H and P with Update
Horacio Kane is a 45 y.o. white male admitted with multiple trauma S/P MVA following a high speed chase. Full code. Allergies as noted. Fall risk secondary to surgery.AAO x3. PMH: GERD, CHF h/o of multiple concussions, HTN, Type II DM.
Admitting Dx: Multiple trauma, concussion, facial lacerations, fx of left tibia and fibula. Pt suffers from a concussion with residual headaches, facial lacerations and multiple fractures of the left lower extremities for which he underwent an ORIF. He is to advance to a Regular diet this am. This is post op day 2.
You do not appreciate any significant issues on your head to toe exam. You are going in to pass your morning meds. You have taken your VS and checked your labs. (Review these results and consider thier implications.)