Patient Details
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Medications |
Fentanyl patch 12mcg/hr Q3daily Paracetamol 1g PO QID Isosorbide mononitrate 60mg mane Nitrolingual spray PRN Hydralazine 12.5mg mane Clopidogrel 75mg mane Famotidine 40mg mane Atorvastatin 40mg nocte Pantoprazole 40mg mane Targin 20/10mg PO BD Endone 5-10mg PO Q4H PRN Ondansetron 4-8mg PO/IV Q4H PRN Clexane 40mg S/C nocte Coloxyl with Senna 2 tabs BD |
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HPC |
The patient was diagnosed with a right neck of femur fracture that required a right hemiarthroplasty the day of admission. There were no intraoperative complications and a minimal to moderate amount of bleeding. The patient had been slow to progress with mobilisation due to a poor baseline and pain. It is now day 3 post the hemiarthroplasty. You have been called to a rapid response for your patient due to desaturation and increased respiratory rate. She states having a cramp in her right calf muscle since the early hours on the morning but did not advise staff. The patient is now feeling SOB, has chest pain, desaturating, tachypnoeic and has a fever. |
|
PSxHx |
Cholecystectomy 2001 Total left knee replacement 2008 |
|
PMHx |
Chronic back pain Osteoarthritis Ischaemic heart disease Hypertension Aortic stenosis Previous TIA Depression Dyslipidaemia GORD |
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Allergies |
Pethidine – Generalised rash Norspan – Nausea |
|
FHx |
Nil relevant family history |
|
SHx |
Patient is a retired school secretary who now lives in a nursing home. She lived alone at home until a few years ago when her mobility became an issue for independent living. She never married but has a very supportive younger sister who is well and lives in Armidale. Patient mobilises with a 4WW and has assistance with some ADLs. She is a lifelong non-smoker and is a non-drinker. |