Resident presented to nurse’s station and informed the nurse he had breathing and congestion, a rash between his buttocks, a laceration behind his right ear, and that his urine was brown. APRN was notified and an order obtained to send resident to FCMC for further evaluation and treatment for shortness of breath.
Chest x-ray conducted with no abnormal findings. EKG results: “Sinus rhythm with occasional premature ventricular complexes. Possible Inferior infarct.” Cardiac consult pending at Le Bonheur. Lab (urinalysis with C&S) was ordered for the discoloration of the urine. Hydrocortisone 1% apply topically between buttock twice daily for 7 days for skin irritation of the buttock. Order to clean right ear with antibacterial soap daily times 5 days and apply TAO daily topically for 7 days (laceration to ear due to “poor hygiene, lack of cleanliness”).