Medical Report on Room 346

Patient Information

• Name: Yvette Ogum
• Age: 34 years old
• Gender: Female
• Admission Reason: Heroin overdose
• Arrival: Ambulance at 1800

Medical History

• Allergies: Aspirin
• Surgical History: Back surgery in 2012
• Chronic Conditions: Depression, Drug abuse
• Previous Admissions: Two prior admissions for heroin overdose
• Rehab History: Sent to rehab three times in the past three years

Current Situation

• Family Status: Going through a divorce, strained relationship with two children
• Substance Use: Possible initial addiction to pain medication post-surgery

Clinical Information

• Naloxone Administered: Two doses (2 mg each)
• Post-Naloxone Reaction: Vomiting (twice)
• Vitals:
  • Blood pressure: 150/85
  • Heart rate: 122
  • Respirations: 22
  • Temperature: 98.6°F
  • Pulse ox: 100% on room air
• Assessment:
  • Alert and oriented x3
  • Lung sounds clear
  • Pulse strong
  • Tender abdomen
  • Track marks on extremities
  • No cellulitis or abscesses noted
  • CAL score: Initially 14, later 35

Current Treatment

• Pain Management:
  • Ibuprofen 400 mg every 6 hours (next dose at 8 a.m.)
  • Request for stronger pain management due to ineffective ibuprofen
• Anxiety and Withdrawal:
  • Showed symptoms of withdrawal, anxious behavior, and vomiting
  • Requested anti-anxiety medication

Nurse's Observations

• Patient Behavior:
  • Anxious, frequently using call-bell
  • Described as "high maintenance" and "drug seeker"
  • Complained of severe pain (rated 25 on scale of 1-10)
  • Vomiting, sweating, and diarrhea reported

Communication with Doctor

• Doctor: Dr. Lopez
• Discussion Points:
  • Patient's withdrawal symptoms and high CAL score
  • Request for stronger pain medication and anxiety treatment
  • Acknowledged severe pain and need for better management

Follow-up Plan

• Nursing Care:
  • Assessment continuation
  • New gown, cool compress
  • Nausea medication
• Patient Support:
  • Assurance of support and plan for post-hospital help
  • Acknowledgment of patient's desire to better for her children

Notes

• Emphasized importance of treating patient with empathy
• Concerns about under-medication and patient labeling
• Commitment to collaborative care for patient recovery