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Medicine Consult Progress Note

Page history last edited by Kendall Rogers 6 years, 8 months ago

Medicine Consult Progress Note

Recommendations by Problem:

>> Problem 1 - Put assessment here

*plan 1

*plan 2

_____________________________________________

ID:

Length Of Stay: 5 Days

24 Hour Events:

Subjective:

Current Medications:

Active Inpt Meds: acyclovir (acyclovir tab/cap) 800 mg By Mouth TID ciprofloxacin (ciprofloxacin inj) 400 mg IV Piggyback q 24 hours famotidine (famotidine tab) 20 mg By Mouth q 24 hours furosemide (Lasix tab) 40 mg By Mouth once a day levETIRAcetam 500 mg By Mouth BID levothyroxine (levothyroxine tab) 25 mcg By Mouth q day before a meal potassium chloride (potassium chloride tab) 20 mEq By Mouth once a day spironolactone 25 mg By Mouth once a day tamsulosin 0.4 mg By Mouth once a day tranexamic acid 325 mg IV Piggyback q 24 hours

Active IV Meds: None Active PRN Meds: acetaminophen (acetaminophen tab) 650 mg By Mouth q 6 hrs nitroglycerin (nitroglycerin 0.4 mg SL tab) 0.4 mg Sublingual q 5 minutes ondansetron (ondansetron inj) 4 mg IV Push TID

Last 48 hr One Time Meds: (Discontinued) furosemide (Lasix inj) 40 mg IV Push once then discontinue (Completed) furosemide (Lasix tab) 80 mg By Mouth once then discontinue

Objective:

Vital Signs Recent (Ranges for last 30 hrs)

Temperature: 36.2 (36.2 - 36.6)

Heart Rate: 90 (90 - 96)

SBP Cuff: 117 (102 - 117)

DBP Cuff: 69 (66 - 70)

MAP Cuff: 85 (78 - 85)

Resp Rate: 18 (18 - 20)

Sp02: 94 (82 - 98)

O2 Flow Rate: 1 (1 - 1)

Dosing Weight: 66.7 kg as of 05/30/13

Height - not entered

Intake and Output Since 07:00AM As of 14:10Intake 0 Output 450 0 mL UOP Balance -450

Previous 07:00AM-07:00AM Intake 933 Output 1300 1950 mL UOP ( 1.2 cc/hr UOP) Balance -367

Physical Exam:

General:

HEENT:

Card:

Chest:

Abd:

Extremities:

Neuro/Psych:

LAB VALUES

CBC

14.3

6.1 |--------------| 68 06/03/13 05:01

43

CHEM7

134 99 84

---------|---------|------------ 06/04/13 09:50

3.6 23 2.47

GLU 156 06/04/13 09:50

Other

CA 8.9 06/04/13 09:14

MG 2.2 06/04/13 09:14

PO4 3.8 06/04/13 09:14

AST (SGOT) 30 U/L 06/03/13 05:40 ALB 2.9 G/DL 06/03/13 05:40

ALT (SGPT) 25 U/L 06/03/13 05:40 T Protein 6.6 G/DL 06/03/13 05:40

ALK Phos 152 U/L 06/03/13 05:40 NH3 - -

GGT - -

T Bilirubin 2.1 MG/DL 06/03/13 05:40

D Bilirubin 0.9 MG/DL 06/03/13 05:40

I Bilirubin 1.2 MG/DL 06/03/13 05:40

Protime: 15.6 SECONDS 06/02/13 04:56 Heparin Level F - -

I.N.Ratio 1.29 RATIO 06/02/13 04:56 Fibrinogen (lab - -

APTT - -

 

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