Patient Initials Age Weight & Height Gender

Patient Initials Age Weight & Height Gender Service Consults Allergies C. Carter 49 210lb. 5’9 M Gastroenterology ibuprofen, lisinopril, throdrenaline, theophyiline, tomato’s. Reaction: hives/rash Patient Health History COPD, asthma, alcohol abuse (8-12 beers a day), hypertension, tobacco abuse, acute bronchitis, cholecystectomy, Pt presented to the Integris-Yukon ED with 9/10 chest pain and was discharged to home with dx of asthma exacerbation and UTI and prescribed prednisone and ciprofloxacin. Pt came back to Integris-Yukon ED two days later (9/12) with complaints of nausea, vomiting and abdominal pain. A non-infused CT of the abdomen showed possible pancreatitis. The second CT showed some short bowel thickening and possible right colon thickening. He was then admitted for acute pancreatitis. MAR for C. Carter Medication Classification Dose/Route/Time Scheduled Times: Indications/Use Dilaudid Opioid algentic 0.5mg/oral/ q3 hrs PRN PRN Pain medication labetol antihypertensive 5mg/IV/q 6hrs 0900, 1500, 2100, 0300 Decrease BP reglan prokinetic 10mg/IV/q 6hrs 0900, 1500, 2100, 0300 Treats nausea and vomiting Dextrose 5% IV solution glucose 40ml/IV/PRN PRN *To be given for FSBS <50 mg/dL Reduces concentration of glucose in blood Novolog antidiabetic 100units/mL/IV/q 4hrs *175-210= 1unit 211-245=2 units 246-300=3 units 301-345=4units >400 notify MD Treats high blood sugar Fluticasone-vilanterol Glucocorticoid 1 puff/resp/daily 0900 Treats COPD Pepcid H2-histamine receptor antagonist 20mg/IVBID 0900, 2100 Treatment of ulcers Lovenox Anticoagulant 40mg/subcut/bedtime 2100 For prevention of DVT Flagyl Antiinfective 500mg/IVPB/q 8 hrs 1200, 2000, 0400 Prevent infection Duoneb Anticholinergic 3mL/resp/q 6hrs PRN PRN To treat & prevent wheezing or shortness of breath Adult central TPN Solution Daily nutrition Continuous @ 100ml/hr 1800 start new bag Nutrition Ciprofloxacin in dextrose 5% Antibiotic 400mg/IV/q 12 hrs (BID) 0900, 2100 Prevention of infection Lomotil Antidiarrheal 2 tab oral q 6 hrs 0900, 1500, 2100, 0300 Decrease diarrhea System Assessment Neuro/Sensory Awake, Alert and oriented x4; states no dizziness on standing. Cardiovascular BP:139/88 Pulse:78 normal heart rate and regular rhythm with no evidence of murmurs cap refill: 2+ pedal pulse:2+ no edema, no cyanosis or clubbing Respiratory RR: 18 O2 sat:93% at room air no shortness of breath, no wheezing or coughing, no secretions; clear lung sounds bilaterally and in all lobes; even & unlabored respirations GI NPO a gtube in place to left upper quadrant; no nausea or vomiting at this time persistent diarrhea; (+) guiac occult testing liquid stool x4 this shift abdomen distended and firm, tender on palpation (most tender in upper R Q) Bowel sounds hypo-active in all quadrants Intake: PO-0 IV: 1250mL GU foley catheter intact; Output: 1188 mL urine: yellow, clear, no sediment No flank tenderness to palpation; Skin Temp:98.9 F Skin is warm, pink and dry with poor turgor; with no rashes, jaundice noted no evidence of breakdown over bony prominences Braden scale:20, picc line in R arm with IVF infusing. No redness or swelling at insertion site. Musculoskeletal assist when ambulating—pt states “I feel so weak.” Normal ROM in all extremities, grips/strength equal bilaterally Endocrine FSBS 0800:221 1000: 188 1200: 201 1400: 196 1600: 155 No history of thyroid disorders Reproductive No complaints at this time. Catheter Care performed no skin breakdown noted. Pain c/o severe pain in lower abdomen 8/10 on pain scale. Pain is described as stabbing and constant Pt reports pain as 5/10 after IV pain meds Psychosocial Pt states that he has good supportive wife, 3 children, and a job he enjoys Labs/Diagnostics WBC: 18,000 RBC: 4.9 hemoglobin: 14.3 hematocrit: 41.6 Amylase: 124 Lipase: 158 Triglycerides: 277 BUN: 8.0 Creatinine: 1.0 Sodium: 142 Potassium: 4.0 Magnesium: 2.0 Chloride: 100 Phosphate: 3.0 AST: 31 ALT: 36 Miscellaneous Based on Mr. Carter’s clinical manifestations (assessment) and lab results, the health care provider suspects the patient has Pancreatitis and possibly an inflammatory bowel disease. What information from the chart supports the diagnosis? Pancreatitis : Inflammatory bowel disease: The patient has a capsule endoscopy done (swallows a camera pill) as a diagnostic test. Results show areas of inflammation in the mucosal layer of the colon only. These findings are characteristic of what specific inflammatory bowel disease? How are each of the inflammatory bowel diseases differentiated? What clinical data from this chart is RELEVANT and needs to be trended because it is clinically significant? *in other words—what labs, vitals, symptoms should be watched closely since they indicate a potential complication? What are the most likely complications to anticipate based on the patient’s diagnoses and clinical manifestations (assessment)? What interventions would prevent these complications from happening?

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