Posted: July 19th, 2021
I will attach the concept map form that needs to be filled out. If the information on patient isn’t given then you can be creative and make it up. JJ is a 65-year old-female Caucasian. DOB: 6/7/xx, Ht. 66 inches and Wt. 70kg. Religion: LutheranHistory of present illness: Mrs. James went to her local senior center complaining of a “sore that just won’t heal”. The nurse at the senior center referred Mrs. James to Dr. Winters for follow-up. Wound culture obtained at clinic and results are pending.BP:178/96mmHgHR:88-IrregularT:101.4°F RR: 26 per min. 02 sat 90%. Pain 7/10. Mrs. James has been admitted to the medical/surgical unit for treatment of a diabetic leg ulcer. Primary Medical Diagnosis: Non-healing leg wound. Past medical diagnosis: Cardiovascular Hypertension, atrial fibrillation, Type 2 Diabetes Past surgical history: Knee replacement. Diet:1800ADA Medication allergies: Penicillin. Home medications: Glipizide (glucotrol)10mg PO twice daily ; Capoten (captopril) 50mg PO twice daily; Lanoxin (digoxin) 0.125mg PO daily; Coumadin (warfarin) 5mg daily PO; Keflex (cefalexin) 500mg PO every 6 hours PO; Bactrim(sulfamethoxazoletrimethoprim) 800mg every 12hours. Labs: Glucose finger stick 200, WBC 5,100, HgBl 1.5, Hct 36.4%, Plt 158,000, K 4.7, Cl 101, Hgb Alc 7%, prealbumin 40, albumin6.5, PT 10.3, PTT 25.7, CK-MB 4.5%,Troponin 0.2 Ug/L Diagnostics: X-ray of the foot, pending results Widowed patient lives alone with 6 cats. She does not drive but walks, uses public transportation or rides with friends. Two adult sons live out of state and have limited interaction with the her. ½ PPD smoker since she was “in her 20s”. Occasional ETOH. Diagnostics: CXR-results pending, EKG results pending. Requirements: just fill the blanks on the form
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