26/JUNE/2020 AT 6:40PM
ADMIT TO: INPATIENT MEDICINE WARD TO THE SERVICES OF DR. RUBEN RUIZ ZAPATA
ALLERGIES: ASPIRIN
DIAGNOSIS: LOWER GI BLEED, DIVERTICULOSIS, HYPOTENSION
CONDITION: OF CARE; PROGNOSIS GUARDED
VITAL SIGNS: QID. 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.
DIET: NPO.
IV FLUIDS: 1 L NS 0.9% FULL DRIP. THEN 0.45% NSS WITH DEXTROSE AT 125 CC/HR.
MEDICATIONS:
IV ANTIBIOTICS: ZOSYN 3.375G Q6H.
-FAMOTIDINE (PEPCID) 20 MG IV Q12H.
-ZOLPIDEM (AMBIEN) 5MG QHS PRN INSOMNIA.
LABS/IMAGING: HEMOGLOBIN LEVELS Q8H x 3. CXR PA AND LAT, ECG, 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 FOR 2U PRBC (HOLD – TO BE TRANSFUSED ONLY IF HGB <8 AND BY CONFIRMATION OF DR. RUIZ ZAPATA).
ANY INQUIRIES CONTACT DR. RUIZ ZAPATA. —NOTE – “HOME MAINTENENANCE MEDS” ARE IRBERSARTAN, LASIX, AVALIDE, METOPROLOL, PROCARDIA. HOLD THESE MEDS AND ONLY ADMINISTER IF INDICATED BY DR. RUIZ ZAPATA.—