Description Name: Kirby BaxterAge: 36 yearsProvider: M. McCall MDAllergies: NKDACode Status: Full C ...

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Description Name: Kirby BaxterAge: 36 yearsProvider: M. McCall MDAllergies: NKDACode Status: Full CodeAdmit Wt: 190 lbs (86.2 kg)BMI: 27.3 Other 09/30 0800Client Information: Medical History: Transient ischemic attack, type 2 diabetes, depression, pulmonary embolism Social History: Smokes 1 pack/day cigarettes Name: Kirby BaxterAge: 36 yearsProvider: M. McCall MDAllergies: NKDACode Status: Full CodeAdmit Wt: 190 lbs (86.2 kg)BMI: 27.3r Lab & Diagnostics Other DIAGNOSTIC TEST RESULTSDateDiagnostic TestFindings09/30 0920 Computed Tomography (CT) Focal cord enlargement at the level of trauma on sagittal T4. Suggested MRI (magnetic resonance imaging) for more detailed imaging. Provider Lab & Diagnostics Other PROVIDER PRESCRIPTIONS & NOTES09/30 0802Prescriptions: Insert two large-bore peripheral IVs 650 mg of acetaminophen by mouth q6h PRN for pain Apply 100% oxygen via nonrebreather mask Complete full neurologic exam Electrocardiogram now Insert indwelling urinary catheter Out of bed to chair three times daily Regular diet 09/30 0925Prescriptions: Morphine 2 mg IV push q3h PRN for pain 0.9% NS 1000 mL IV fluid bolus – infuse over one hour Collect urine sample Orthostatic vital signs - once CBC level Lower the head of the bed Flowsheets Provider Lab & Diagnostics Other VITAL SIGN TRENDDate TempHRRRBPSpO2O209/30 074598.0 °F (36.7 °C)462888/5299%2L/NC09/30 0930 98.0 °F (36.7 °C)5816 100/80 99% RA  Age: 36 years Provider: M. McCall MD Allergies: NKDA Code Status: Full Code Admit Wt: 190 lbs (86.2 kg) BMI: 27.3 Nursing Flowsheets Provider Lab & Diagnostics Other NURSING ASSESSMENT & NOTES09/30 0750 Neuro/Cognitive: Alert, oriented to person, place, time, and situation. Slow to answer questions. Cardiovascular: S1 and S2 sounds present. Denies chest pain. Sinus bradycardia. Respiratory: Breathing rapid. Equal chest rise and fall. Genitourinary: 16 F indwelling urinary catheter draining yellow, clear urine. Neurovascular: Numbness and tingling along with decreased sensation to lower extremities. Pain: Rates 9/10 pain. “My neck is killing me!”