ADMIT - DIABETIC ULCER

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Admit to: INPATIENT MEDICINE WARD UNDER THE SERVICES OF DR. DELGADO

Diagnosis: SEPSIS, Pneumonia, DVT R/O, DM2, HTN.

Condition: OF CARE; PROGNOSIS GUARDED

Vital signs: q4H. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C or O2 saturation <90%.

Activity: BEDREST. BEDSIDE COMMODE.

Admit to: INPATIENT MEDICINE WARD UNDER THE SERVICES OF DR. DELGADO

Diagnosis: DIABETIC ULCERS LEFT LEG, PERIPHERAL VASCULAR DISEASE, SEPSIS, DM2, HTN.

Condition: OF CARE; PROGNOSIS GUARDED

Vital signs: q4H. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C or O2 saturation <90%.

Activity: BEDREST. BEDSIDE COMMODE.

Nursing: Keep affected extremity elevated; warm compresses prn.

Diet: DIABETIC LOW SODIUM, FREE FROM IRRITANTS, 2000KCAL.

IV Fluids: 1L 0.45% NSS AT RATE OF 80CC/HR.

MEDS:
-ABx:
-CEFEPIME 2GM IV Q8H.
-Docusate sodium (Colace) 100 mg PO qhs.
-PEPCID 20MG IV Q12H.

HOME MAINTENANCE MEDS TO BE ADMINISTERED ONLY BY CONFIRMATION OF DR. DELGADO:
-PLAVIX

-REGULAR INSULIN AS PER SLIDING SCALE:
DEXTROSE UNIT
151-200 3U
201-250 5U
251-300 7U
301-350 9U
351 + 12U

Labs: CBC WITH DIFFERENTIAL,CMP, BLOOD CULTURE Q15MIN x 3 (CULTURE AND SENSITIVITY), WOUND CULTURE AND SENSITIVITY. GLYCOSYLATED HGB. URINALYSIS, URINE CULTURE. LABS/IMAGING: D-DIMER, CXR PA and LAT, ECG. SED RATE, CRP. PROCALCITONIN. LACTATE, LDH. COVID RAPID TEST. —REPEAT TOMMORROW IN AM CBC WITH DIFF, D-DIMER, CMP.

ANY INQUIRIES CONTACT DR. DELGADO.

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