ADMIT - LOWER GI BLEED

Posted

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 MEDSARE IRBERSARTAN, LASIX, AVALIDE, METOPROLOL, PROCARDIA. HOLD THESE MEDS AND ONLY ADMINISTER IF INDICATED BY DR. RUIZ ZAPATA.—

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