1. Patient: CS
Has a history of hypertension, diabetes, depression, renal calculi, and cholesterol
Allergic to Jardiance and latex.
Patient lives at home with husband and 2 children (1 boy and 1 girl)
She does have a little financial problem related to her husband who recently lost his job.
She has a great support system and mother and father her care for her as well.
She is Christian but doesn’t really have any spiritual considerations
2. Medical diagnoses
Has a brain tumor which turned out to be glioblastoma in the frontal lobe (suggested to be a high-grade tumor.
Patient had a seizure in September and was brought to the hospital by her husband and when the doctor did a CT scan on her they found that she had a tumor that was large.
She returned 1 month later for an elective excision of tumor and a craniotomy. At my care she was 3 days post op and had staples from the middle of her forehead to the left side of her cheek bone.
She had a hemovac drain with serosanguinous drainage
Her blood sugar was 406
Vital signs were
Heart rate -42
Blood pressure- 187/81
Oxygen level was 95%
Temperate was at 98.2F
Respiratory rate was 20
Clonidine 0.2 3xper day (blood pressure )
Januvia 25mg 1x/day
Keppra 500mg 1 every 12 hours (for seizures)
Metformin 1000 mgx2/day (blood sugar)
Omeprazole 20mg x1/day (heart burn)
Zoloft 100mg 1x/day (depression)
Zocor 20mg for cholesterol
Lantus solostar pens for blood sugar
Norco 5/325 every 4 hours as needed for pain