Summary Dorel McAlister DOB 01/02/ 1939
Patient Summary
| MRP | Dr. Lisa Gray 98765 / Dr James 12345 | |||||
| Admit Date | 2 days ago | |||||
| Primary Diagnosis | Bowel resection for Small bowel obstruction | |||||
| SECONDARY DIAGNOSES | COPD | |||||
| hypertension | ||||||
| Blood Consent | n/a | Blood Type: | ||||
| Aggression | History of Violence: no | Physically Aggressive: | no | |||
| Behavior | Verbally Aggressive: n/a | Violence Prevention Toolkit: n/a | ||||
| Religion | Catholic | |||||
| OXYGEN | 2 liters nasal prongs | SUCTION | —- | |||
| SURGERY | Sigmoid resection | |||||
| DRAIN | JP – abdomen | |||||
| WOUND | abdominal dressing | |||||
| Precautions | universal | Code Status: | MOST | |||
| Substance Use | none | Last Use: | n/a | |||
| Alcohol Use | social | Last Use: | pre hospitalization | |||
| Tobacco Dependence: | none | Last Use: | pre hospitalization | |||
| ALLERGIES | Reaction type: | NKA | Severity: | |||
| Reaction type: | Severity: | |||||
| Reaction type: | Severity: | |||||
| DIET | fluids – DAT (diet as tolerated) | |||||
Patient Monitoring
| DIET | Full fluids (FF) – DAT (diet as tolerated) | |||||
| V S | @0600 today | Temp (C) 36.9 | Pulse 74 reg | Resp Rate 14 | BP 118/64 | SpO2 88% 2L nasal cannula |
| Pain: | 4-5/10 | Analgesics: | epidural | Dressings: | abdomen | |
| FOLEY | Day —– | Night —– | D/C date: | foley removed day 1 post op | ||
| TUBES | Type: JP-abdomen | |||||
| IV Lines: | PVAD short – Right forearm | |||||
| Intake: | IV RL@60cc/hr oral: 150 cc | Output: | urine > 30cc/hr | |||
| Pending Tests & Diagnostics: | PTT subtherapeutic. Note left for MRP | |||||
