Summary Adir Azibo 02/02/1968
Patient Summary
| MRP | Dr F. Racture | |||||
| Admit Date | Yesterday | |||||
| Primary Diagnosis | Fever NYD | |||||
| SECONDARY DIAGNOSES | High blood pressure Obstructive sleep apnea (uses BiPAP at night) GERD (gastro esophogral reflux disease = heartburn) Diabetes type 2 – diagnosed 20 years ago – managed with metformin, diet, and exercise. BPH (benign prostatic hypertrophy – 5 months) | |||||
| Implanted Device | ||||||
| Blood Consent | Blood Type: | |||||
| Aggression | History of Violence: | Physically Aggresive: | ||||
| Behaviour | Verbally Aggresive: | Violence Prevention Toolkit: | ||||
| Religion | ||||||
| OXYGEN | SUCTION | |||||
| SURGERY | Open Reduction and Repair of left tibia 8 days ago. Discharged with exposed pin site care. | |||||
| DRAIN | ||||||
| WOUND | Half-slab cast and tensor on his left lower leg with exposed pins | |||||
| Isolation | Code Status: | Link to MOST | ||||
| Substance Use | Last Use: | |||||
| Alcohol Use | Last Use: | |||||
| Tabacco Dependence: | Last Use: | |||||
| ALLERGIES Penicillin | Reaction type: | unknown | Severity: | unknown | ||
| Reaction type: | Severity: | |||||
| Reaction type: | Severity: | |||||
| DIET | Diabetic Diet as tolerated | |||||
Patient Monitoring
| DIET | Diabetic Diet as tolerated | |||||
| V S | DAY Yesterday 2100 | Temp (F) 38.0 | Pulse 94 bpm | Resp Rate 18 | BP 160/84 | O2 94% RA |
| I & O | ||||||
| FOLEY | Day | Night | DC date: | |||
| TUBES | Type: | Type: | ||||
| IV Lines: | NS@75 cc/hr | Pain: | Pain Level: | |||
| Collection: | Intake: | Output: | ||||
| Pending Tests & Diagnostics: | Daily CBC, lytes, Troponin, Mg, Phos, glucose, A1C x 4 days Cultures: Urine DONE,, Sputum, Blood cultures x 3 DONE, wound / pin sites DONE | |||||
| Appointments: | ||||||
| Blood Glucose (Time/ Reading) | ||||||
