The nursing notes for the patient are shown below. The patient was given 3 doses of morphine, each 4mg. She was also given 1L of fluids through a 22 gauge IV.
The patient’s vitals throughout her stay were recorded by nursing staff. Her heart rate improved from 100bpm to 89bpm. Her blood pressure was normal throughout, with final reading 139 systolic. Respirations were in the low 20s. Her pain started at a 9, improved to a 4, but the final recorded pain score was back to a 9.
The doctor was aware of all of this information. He diligently evaluated the patient’s results, and reviewed the case with the patient’s surgeon. The surgeon recommended bedside drainage of an area that was clinically suspect for abscess. The 2 physicians arranged a follow-up for the patient as well. She was given good instructions for return precautions, medication to help manage her pain at home, and started on antibiotics. She was then discharged.
The physician typed up a thorough report about his care that was over a page long. He describes her presentation, test results, and the conversation he had with her surgeon. This note is very high quality, and will be assessed further in the documentation review section of this case. It is available for email subscribers below.
Despite the follow-up plan and medication to manage her symptoms at home, the patient would return just a few hours later. Continue to the next page to see what happened at her return visit.