H and P with Update
H and P not available. Voice Care report taped and transcribed
“Mr. Aragorn is an elderly patient of Dr. Karloff.
I don’t seem to have his age here.
No allergies.
He came to us after a motor vehicle accident yesterday.
He went to surgery.
They took out his spleen.
They also repaired a lacerated liver.
He had perforated his bowel. He was going to have a colostomy but they pieced him back together.
He has fractured ribs - both sides.
They also had to do an amputation of his left foot. It wasn’t salvageable.
He has a history of:
Coronary artery disease
COPD
Diabetes
His last set of Vitals :
Temp 98.4
Heart rate 96. But he has been that high on admission
Respirations 24
BP 140/88
Sats at 96 on 2 l
IV is D5 NS at 120/hour
He rated his pain a 10 out of 10 about an hour ago, but he didn’t want anything which was ok with me. This night has just been terrible. Megan called off again, and then the code; I need to go home.