Concept Map with attachment of the template on how we are to write the concept map witing is to be done inside the box.
CaseStudy
Mr. W.M is an 46yrs who is admitted from the hospital for pain control on his left sided flank arm and a periodic shortness of breath. In the hospital he was diagnose with Acute Pulmonary Embolism with likely Pulmonary Infraction.
He said the pain is due to a surgery that he had on his left should 2 weeks ago.
He also reported that he was in his normal state of health post operation.
So, his left upper extremity sling was completely immobile for approximately 1 – 2 weeks after surgery.
He said he had no swelling, no blood clot, and no bleeding.
He said he could not shower, that the pain makes him uncomfortable
He has no dizziness, no lightheadedness, no palpitation
He is allergy to Penicillin
He is on Full Code and on a fall precaution (risk)
He is well alert and orientated
His heart sound was regular
Clear respiration
He was in a regular and tolerated diet.
You complete your assessment, and these are your findings
Oriented to self and everyone
Can tell you the day, time or state his name.
Vital Signs were as follow; Temperature was 98.8 F Taken Orally
Heart Rate 76 regular
Respiration 18
Blood Pressure 123/69
SPO2 96 and was on room air
HEENT
Eyes, ear, Nose, Throat, were all intact
No nasal drainage color or consistency.
Lips was symmetrical, Tongue was pink and moist, Voice was deep, Teeth was all full, Head and neck were Symmetrical
No CT findings on right heart strain
Bilateral pulmonary emboli, including embolus in the right pulmonary artery
Borderline sized, fluid filled appendix without ancillary, features of acute appendices , abdomen was soft ,not tender , no distended ,no extremities edema
Recent Lab
Glucose 108, Creatine 0.9,Sodium 140 ,Potassium 4.3 , Chloride 103 ,CO2 24 , Calcium 9.1 , Cardiac Markers was high
Medications
Morphine injection 4mg intravenous
Heparin injection 10,000 units
Hydrocodone acetaminophen 325mg
Ondansetron injection 4mg
PRN medications
Oxycodone 325mg
Naloxone injection 0.2mg
Discharge medications
Lidocaine 5%
Rivaroxaban 15mg tabs
Claritin PO
Ibuprofen 800mg
Tylenol PO
STOP Medication
Oxycodone 5mg immediately
He was discharge home after two days and was asked to follow up with his primary care physican and was required to do 3months of therapy
( Below is the Template of the concept map attachment to write inside)
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