eumation Modified from Fundamentals Scenario 11–Kyle Miller (SLS)
Kyle Miller is a 41 year old Caucasian male who was admitted yesterday morning for a low-grade
fever and cellulitis of the forearm secondary to a recent puncture wound. Patient is a carpenter. IV
antibiotics were administered and the affected area was cleaned and covered with dry gauze. Kyle's
temperature has since returned to baseline, and he is slated for discharge today at 1000am.
▸ On assessment his vital signs are as follows: 37.8C-72- 16 - 116/70-99% RA
Patient is awake lying comfortably in bed. States he feels fine and states he has noticed the redness
to his arm seems to be less than yesterday. States pain is 2/10 on scale, non-radiating, and localized to
right forearm. No other voiced concerns and patient is anxious to go home.
On physical assessment, patient is awake, alert, oriented X 3. GCS 15/15. Pupils 3mm, equal and reactive
to light and accommodation. Strong motor response X 4. No complaints of abnormal sensation.
Chest rise and fall bilaterally, no increased work of breathing noted. Patient able to speak in full
sentences. No pain on palpation to thorax. Lungs auscultated and clear to the bases bilaterally.
Peripheral pulses strong X6 (radial, posterior tibial, dorsalis pedis). Cap refill <2 seconds to upper
and lower nail beds. Reddened skin noticed to right inner forearm. Swollen in appearance compared to
left forearm. Warm to touch. Dressing changed, cleaned with normal saline, puncture site closed and
healing. No discharge noted from wound. Surrounding skin is pink and intact. Dry gauze dressing clean,
dry and intact. Abdomen soft, non-distended, round in contour. Bowel sounds present X 4. No pain on
light palpation. Percussion sounds tympany throughout, with dullness to RUQ. Voiding independently,
no complaints of pain or burning. Light straw in color. Last bowel movement yesterday evening, formed
and soft. No issues with mobility, independent in all activities. Patient is pleasant and cooperative and
looking forward to going home.
Questions (include your reference as needed or appropriate)​