JUST COMPLETE THE TEMPLATE
Floyd Dunmire
10/19 0715 | Neuro/Cognitive: Alert, oriented x 4. Speech clear. Calm but somewhat disoriented, cooperative with staff. Pupils 4 mm PERRLA bilaterally. GCS: 15. Cardiovascular: S1/S2 sounds present. HR regular, even. +2 pitting edema from feet to thighs. +pedal pulses with doppler, +2 radial pulses. Respiratory: Dyspnea on exertion and with lying supine. Breathing nonlabored when sitting upright. Lung sounds diminished bilaterally. No cough. Gastrointestinal: BS present x 4 quadrants, normoactive. Abdomen soft, round, distended, non-tender. States abdomen is more distended than normal. Integumentary: Yellowing of sclera and skin. Skin turgor elastic. Skin warm, dry. Red/purple bruising noted from ankles to pretibial region. Lines/Drains: 20-gauge IV site in R hand. Patent, intact. Dressing clean, dry, intact. |
Date | Temp | HR | RR | BP | SpO2 | O2 |
10/19 0800 | 98.2 °F | 92 | 22 | 142/82 | 95% | RA |
OTHER TRENDING DATA | |
Date | Weight |
10/19 0715 | 234.2 lbs (106.2 kg) |
10/17 2310 | Admission Prescriptions:
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10/19 0900 | Prescriptions:
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Date | Lab | Normal | Result |
10/19 0830 | Complete Blood Count (CBC) |
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| Red Blood Cells (RBC) | 4.2 - 5.9 cells/L | 4.2 |
| Hemoglobin (Hgb) | 12 - 17 g/dL | 12.8 |
| Hematocrit (Hct) | 36% - 51% | 38 |
| White Blood Cells (WBC) | 4,000 - 10,000 mm3 | 7,200 |
| Platelets | 150,000 - 350,000 mm3 | 89,000 L |
10/19 0830 | BMP |
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| Blood Urea Nitrogen (BUN) | 8 - 20 mg/dL | 19 |
| Creatinine | 0.7 - 1.3 mg/dL | 1.2 |
| Potassium (K) | 3.5 - 5.0 mEq/L | 4.1 |
| Sodium (Na) | 136 - 145 mEq/L | 138 |
| Calcium (Ca) | 9 - 10.5 mg/dL | 9.9 |
| Chloride (Cl) | 98 - 106 mEq/L | 102 |
| Glucose | 70 - 100 mg/dL | 89 |
| Albumin | 3.5 - 5.0 g/dL | 2.9 L |
10/19 0830 | Aminotransferase, Alanine (ALT) | 0 - 35 U/L | 132 H |
10/19 0830 | Aminotransferase, Aspartate (AST) | 0 - 35 U/L | 79 H |
MEDICATION ADMINISTRATION RECORDMedication10/19 090010/19 0920Medication: Spironolactone
Dosage: 50 mg
Route: By mouth
Frequency: Three times daily
Parameters: N/ATLM Medication: Furosemide
Dosage: 40 mg
Route: IV Push
Frequency: Daily
Parameters: N/A
TLM Medication: Potassium Chloride ER
Dosage: 40 mEq
Route: By Mouth
Frequency: Daily
Parameters: Hold for K+>4.5
TLM Medication: Albumen 25%
Dosage: 50 g
Route: IV
Frequency: Once
Parameters: Administer over 1 hour
TLM
10/19 0700
Medical History: Hepatic steatosis, alcoholism, hypertension
Social History:
Former drinker – approximately 12-12oz beers daily.
Denies smoking history or recreational drug use.
Name: Floyd Dunmire
Age: 58 years
Provider: N. Billows MD
Allergies: NKA
Admit Wt: 228 lbs (103.4 kg)
Code Status: Full Code
BMI: 30.1
Medical History: Hepatic steatosis, alcoholism, hypertension Social History:
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10/19 1630 | Procedural Note: |
10/19 2000 | Client Education: What: Home Management
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