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Stone
Tori Merrick
Created on November 16, 2024
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Transcript
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
POD 1 bilateral mastectomy
Surgical History
Summary
Acne Smoker 1 PPD X 12 years Depression Anxiety
Medical History
Order Kardex
MAR
Labs
Vitals
Full Code Allergies: None
Michele Stone "Michael" 32 yo, 11/8/XX transgender male
Summary
Order Kardex
MAR
Labs
Vitals
Summary
Order Kardex
MAR
Labs
Vitals
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%
Summary
Order Kardex
MAR
Labs
Vitals
Given 4hrs ago
Oxycodone/acetaminophen 5/325mg PO Q4H PRN mild pain
Hydromorphone 1mg IVP Q6H PRN moderate to severe pain
Ketorolac 2mg IM Q6H
Sertraline 25mg PO daily
Testosterone undecanoate 160mg PO daily
LR 100 ml/hr
Summary
Order Kardex
MAR
Labs
Vitals