ADMIT - PNEUMONIA R/O DVT

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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.

Nursing: CONTINUOUS CARDIAC MONITORING (TELEMETRY), inputs and outputs (CHARTED). DEXTROSTIC Q4H.

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

IV Fluids: 1L 0.45% NSS at 70 cc/hr.

Medications:
-Oxygen by NC at 2L/min to maintain O2 saturation >92%.
-CEFTRIAXONE 1GM IV Q24H
-AZITHROMYCIN 500MG IV Q24H
-Acetaminophen (Tylenol) 650 mg 2 tab PO Q6h prn temp >38/C or pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-PEPCID 20MG IV Q12H.
-LOVENOX SC 90MG DAILY.

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

LABS/IMAGING: D-DIMER, CXR PA and LAT, ECG. CBC with differential, CMP, ABG. Blood CULTURE (CULTURE AND SENSITIVITY) Q15MIN x 3. URINALYSIS & urine culture. DOPPLER VENOUS LEFT LOWER EXTREMITY. SED RATE, CRP. PROCALCITONIN. LACTATE, LDH. REPEAT TOMMORROW IN AM CBC WITH DIFF, D-DIMER, CMP, COVID RAPID TEST & COVID PCR.

ANY INQUIRIES CONTACT DR. DELGADO.

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