Report 1 2
Report 1 2
Report 1 2
Subjective
CC: Feels better
Health Status
Allergies:
Allergies (1) Active Reaction
morphine None Documented
Objective
Intake and Output
Intake and Output (ST)
01/02/20 01/01/20
VS/Measurements
Vital Signs
1/2/2020 7:44 AM EST Heart Rate Monitored 68 bpm
Oxygen Saturation 99 %
1/2/2020 7:44 AM EST Nursing Respiratory Rate 18 br/min
Oxygen Flow Rate 2 L/min
Oxygen Flow Rate 2 L/min
Oxygen Therapy Nasal cannula
Oxygen Therapy Nasal cannula
1/2/2020 7:43 AM EST Temperature Oral 36.4 DegC
1/2/2020 7:43 AM EST Systolic BP 143 mmHg HI
Diastolic BP 77 mmHg
Mean BP 99 mmHg
1/2/2020 6:53 AM EST Heart Rate Monitored 73 bpm
Results Review
Inpatient Vitals/Meds/Labs
Vitals
Vital Signs (last 24 hrs)_____ Last Charted___________
Resp Rate 18 br/min (JAN 02 07:44)
SBP H 143mmHg (JAN 02 07:43)
DBP 77 mmHg (JAN 02 07:43)
SpO2 99 % (JAN 02 07:44)
BMI 35.57 (JAN 02 00:18)
Meds
Medications (22) Active
Scheduled: (13)
aspirin 81 mg Tab Enteric 81 mg 1 tab, PO, Daily
atorvastatin 40 mg Tab 40 mg 1 tab, PO, Daily
carvedilol 6.25 mg Tab 6.25 mg 1 tab, PO, BID
levothyroxine 0.112 mg Tab 112 mcg 1 tab, PO, Daily
lisinopril 20 mg Tab 20 mg 1 tab, PO, Daily
MEDICATION INSTRUCTION: PHARMACIST: ORDER TELE MONITORING ORDERS 1 EA, Rx Dosing, Once Med
MEDICATION INSTRUCTION: PHARMACIST: ORDER TELE MONITORING ORDERS 1 EA, Rx Dosing, Once Med
nystatin TOPical Powder 1 app, Topical, TID
pantoprazole 40 mg Tab Enteric 40 mg 1 tab, PO, Daily
PNEUMOVAX VACCINE 0.5 mL Inj 0.5 mL, IM, Daily+
rivaroxaban 10 mg Tab 10 mg 1 tab, PO, Daily w/Supper
SALINE (NS) FLUSH 1 syringe, IV Flush, Q8HR
Tegretol tab 200mg 1 EA, PO, Q8HR
Continuous: (0)
PRN: (9)
acetaminophen 325 mg Tab 650 mg 2 tab, PO, Q6HR
atropine 0.5 mg/5 mL Pre Fill Syringe 0.5 mg 5 mL, IV Pus h, Daily
magnesium hydroxide 8% UD Oral Sus 30 mL, PO, Daily
metoprolol 5 mg/5 mL Inj 5 mg 5 mL, IV Slow Push, Q4HR
morphine 2 mg Inj 2 mg 1 mL, IV Push, Daily
nitroGLYCERIN 0.4 mg Tab SL 0.4 mg 1 tab, SubLingual, Q5Min
ondansetron 4 mg Tab ODT 4 mg 1 tab, PO, Q8HR
ondansetron 4 mg/2 mL Inj 4 mg 2 mL, IV Slow Pus h, Q8HR
tramadol 50 mg Tab 50 mg 1 tab, PO, Q12HR
Labs
Labs (Last four charted values)
WBC 4.3 (JAN 02) 5.1 (JAN 01)
Hgb L 10.5 (JAN 02) L 11.9 (JAN 01)
Hct L 33.2 (JAN 02) 37.1 (JAN 01)
Plt 277 (JAN 02) 312 (JAN 01)
Na 141 (JAN 02) 138 (JAN 01)
K 4.1 (JAN 02) 4.5 (JAN 01)
Cl 106 (JAN 02) 106 (JAN 01)
Cr 1.1 (JAN 02) 1.0 (JAN 01)
BUN H 27 (JAN 02) H 26 (JAN 01)
Glucose 97 (JAN 02) H 110 (JAN 01)
Mg 2.1 (JAN 01)
Ca L 8.0 (JAN 02) 8.8 (JAN 01)
PT 14.0 (JAN 01)
INR 1.1 (JAN 01)
PTT 28.7 (JAN 01)
Troponin <0.05 (JAN 01) <0.05 (JAN 01) <0.05 (JAN 01)
history of CAD with a stent placed however is unsure of when the stent was placed. She does not have a local
cardiologist.
Hospital course:
Ruled out MI
Continue telemetry
1/2/20: Ordered stress test, to be done in a 2 day protocol per cards. No chest pain now
2. Paroxysmal A. fib/flutter
On Xarelto
3. Syncope
Continue telemetry
4. Hypertension
OK vitals
5. Dyslipidemia
Statins
6. Hypothyroidism
7. Elevated d-dimer
CTA chest:. Normal CTA chest examination, without a demonstrated pulmonary embolism or arterial dissection. COPD.
Cardiomegaly.
8. History of CAD/stent
ASA
9. Disposition
Home needs depending on PT/OT eval
Lives with son
Signature Line
Electronically Signed By: Soto, MD, Adolfo
Date / Time Signed: 01/02/20 12:56 PM