ADMIT - DIARRHEA WITH GI BLEED AND ASCITIS AND DIABETIC

Posted

26/JUNE/2020 AT 6:40PM

ADMIT TO: INPATIENT MEDICINE WARD TO THE SERVICES OF DR. RUBEN RUIZ ZAPATA

ALLERGIES: BENZOCAINE

DIAGNOSIS: LOWER GI BLEED, DIVERTICULOSIS, ASCITIS.

CONDITION: OF CARE; PROGNOSIS GUARDED

VITAL SIGNS: Q2H x 2, THEN Q4H AND CHART. CALL PHYSICIAN IF BP SYSTOLIC >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C

ACTIVITY: BEDSIDE COMMODE.

NURSING: INPUTS AND OUTPUTS (CHARTED). NOTIFY MD IMMEDIATELY IF BLOOD IN STOOL OR BLOOD PER
RECTUM. RAILS UP, FALL SAFETY PRECAUTIONS!!

DIET: NPO.

IV FLUIDS: 1 L 0.45% NSS WITH DEXTROSE 5% AT 125 CC/HR.

MEDICATIONS:
-IV ANTIBIOTICS: CEFTRIAXONE IV 1G Q24H.
-LEVOTHYROXINE 112MCG ONCE DAILY
-FAMOTIDINE (PEPCID) 20 MG IV Q12H.
-ZOLPIDEM (AMBIEN) 5MG QHS PRN INSOMNIA.

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

LABS/IMAGING: ADMINISTER 1 UNIT OF PLASMA Q4H x 3. REPEAT PT/PTT/INR AT 12AM AND 4AM. HEMOGLOBIN LEVELS Q8H x 3. CXR PA AND LAT, ECG, ABGs, TROPONINS, CT SCAN ABDOMINO-PELVIC WITHOUT CONTRAST. CBC WITH DIFFERENTIAL, CMP, AMYLASE, LIPASE, BLOOD CULTURES Q15MIN X 3. URINALYSIS WITH CULTURE AND SENSITIVITY. AST, ALKALINE PHOSPHATASE, PT/INR/PTT, BLOOD TYPE AND CROSS.

ANY INQUIRIES CONTACT DR. RUIZ ZAPATA. —NOTE – “HOME MAINTENENANCE MEDSARE LIVALO PO 2MG ONCE DAILY, FLOMAX PO 0.4MG ONCE DAILY, GLIMEPIRIDE PO 4MG ONCE DAILY, NORVASC PO 5MG ONCE DAILY, PLAVIX 75MG ONCE DAILY, LOSARTAN PO 50MG ONCE DAILY, METROPROLOL SUCCINATE ER PO 50MG ONCE DAILY >>> HOLD THESE MEDS AND ONLY ADMINISTER IF INDICATED BY DR. RUIZ ZAPATA.—

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