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Stone
Tori Merrick
Created on November 16, 2024
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Transcript
Vitals
Labs
MAR
Order Kardex
Summary
Michele Stone "Michael" 32 yo, 11/8/XX transgender male
Medical History
Acne Smoker 1 PPD X 12 years Depression Anxiety
Full Code Allergies: None
Patient began hormone replacement therapy at the age of 18. Family has been very supportive. Presented yesterday for bilateral mastectomy. Neuro: A&O x4 Access: 18 g PIV R forearm Respiratory: RA, clear lung sounds GI: positive bowel sounds Integumentary: bilateral incisions with staples, DSD, ACE wrap. Bilateral JP drains present- serosanguinous drainage Pt is complaining of 10/10 stabbing pain to right and left incisions
Surgical History
POD 1 bilateral mastectomy
Vitals
Labs
MAR
Order Kardex
Summary
Vitals
Labs
MAR
Order Kardex
Summary
Vitals
Labs
MAR
Order Kardex
Summary
VS Every 4hrs Regular diet Strict I/Os every 4hrs Activity as tolerated IS every hour while awake Notify provider for: Temp ≥ 38.5, UOP ≤ 240ml/8hrs, SBP ≥ 120 ≤ 90, DBP ≥90 ≤60, HR ≥120 ≤ 60, RR ≥28≤12, O2 sat <92%
Vitals
Labs
MAR
Order Kardex
Summary
LR 100 ml/hr
Testosterone undecanoate 160mg PO daily
Sertraline 25mg PO daily
Ketorolac 2mg IM Q6H
Hydromorphone 1mg IVP Q6H PRN moderate to severe pain
Given 4hrs ago
Oxycodone/acetaminophen 5/325mg PO Q4H PRN mild pain