Stonyfield

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Summary

Rebecca Stonyfield 55 yo, Female

Medical History

HTN, CAD, Chronic back pain

Patient admitted two days ago for chronic back pain with numbness and tingling in R leg for 6 months. Neuro: Alert and Oriented x4 Cardiac: NSR Access: L forearm PIV Respiratory: Lung sounds clear and equal bilaterally GI: Positive bowel sounds Vascular: CMS intact Integumentary: Incision CDI, closed with staples covered with ABD pad. Hemovac draining moderate amount of serosanguineous drainage Patient complaining of 5/10 sharp incisional pain You note: bilateral crackles on auscultation Hemovac output: 80ml/4hrs, serosanguineous

Full Code Allergies: None

Surgical History

POD 1 Laminectomy L2-L5

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Summary

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Summary

VS & CMS Every 4hrs Heart Healthy diet Strict I/Os every 4hrs OOB as tolerated with TSLO brace IS every hour while awake CBC, 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%

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Summary

Metoprolol 50mg PO Daily

Atorvastatin 20mg PO Daily

Docusate Sodium 100mg PO daily

Senna 1 tab Daily

Acetaminophen 650mg PO Q6H

NS 100ml/hr

Hydromorphone (10mg/50ml) PCA dose 0.3mg, Lockout interval 10 min, Max 1hr limit 1.8mg, loading dose 0.3 mg

Ondansetron 4mg IVP PRN Q6H nausea

Diphenhydramine 25mg IVP PRH Q6H itching