Whitmore

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MAR

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Summary

Jason Whitmore 48yo African American Male

Medical History

Patient admitted two days ago from provider's office with non-healing diabetic foot ulcer on L great toe with absent DP/PT pulses. Patient reported pain and swelling for two weeks. Yesterday patient went for an angiogram on his L leg. Scheduled for L leg bypass graft Wednesday. Neuro: A&O x4 Access: 18 g PIV R forearm, 20 g PIV L forearm Respiratory: RA, clear lung sounds GI: positive bowel sounds Vascular: Positive DP/PT pulses on right, doppler only on left Integumentary: L groin angiogram site closed with glue and OTA, L toe ulcer drsg CDI Running Infusions: Heparin 920units/hr (23ml/hr) Container or bloody emesis at bedside

HTN, DM 2 on insulin, Tobacco abuse 1 pack per day x 30 years, PAD (newly diagnosed)

Full Code Allergies: None Jehovah's Witness

Surgical History

4th and 5th R toe amputations (previous ulcers)

Vitals

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MAR

Order Kardex

Summary

Vitals

Labs

MAR

Order Kardex

Summary

Vitals

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MAR

Order Kardex

Summary

VS Every 4hrs 2000 cal ADA diet Saline lock IV Activity as tolerated, NWB left toes IS every hour while awake DSD left foot BG before meals and at bedtime Heparin gtt per protocol CBC, aPTT, Chem-7 daily 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

Heparin continuous per protocol 20,000 units/500ml

Heparin Protocol

920 units/hr

Humalog insulin SQ per sliding scale before meals and at bedtime

Lisinopril 20mg PO daily

Ceftriaxone 1gm IV Q12H

Hydromorphone 1mg IVP Q6H PRN moderate to severe pain

Acetaminophen 650mg PO Q4H PRN mild pain or fever