John Doe Summary

 This patient is John Joe for educational purposes ONLY.

Patient: 59-year-old male
Code Status: Full Code
Admission Date: 5/13
Chief Complaint: Abdominal pain → appendicitis s/p laparoscopic appendectomy

Neuro:

• AOx3, but forgetful

• CT head (done for AMS/confusion) → negative

Respiratory:

• On room air

• Persistent cough, Robitussin with minimal relief

• Hx: RLL abscess → pigtail drain in place

  • Drain to gravity, 10 cc flush BID

Cardiovascular:

• On heparin drip for DVT of left arm

  • Rate: 14 U/kg/hr

• +3 pitting edema, all extremities

GI:

• NPO (pending IVF revision and central line)

• NG tube previously placed, now discontinued

• Appendicitis s/p lap appy

• C. diff infection – isolation

• Rectal tube in place → due for removal today

GU / Renal:

• PMH: CKD, on HD (MWF)

• Access:

  • Left AVF (nonfunctional)

  • Right chest permacath in use

Endocrine / Metabolic:

• PMH: Diabetes mellitus

• Accu-Chek q6h

• On D10 infusion at 50 mL/hr via right IV access

• TPN on hold

Hematology:

• Bruising of left arm

• On heparin drip (see CV section)

Skin / Musculoskeletal:

• Left heel pressure ulcer → daily dressing

• Bedrest at baseline

• Requires 3-person assist for turns/repositioning

• Specialized bed in use

Infectious Disease:

• Sepsis (secondary to RLL abscess)

• Currently has pigtail drain in place for abscess management

• On isolation for C. diff