Progress Report

Patient: 91F

• Dx: Bilateral pneumonia

• PMH: CHF, Afib, CKD, TIA, HTN

• Status: DNR

• Neuro: A&O x4

• Resp: 2L NC baseline, BiPAP at HS

• CV: Stable

• GI/GU: Purewick for incontinence, bedpan for BM

• Mobility: Bedrest, requires 1–2 assist with walker

• Diet: 2g sodium

• Access: None noted

• Plan: Discharged home with daughter today

Patient: 46M

• Dx: Colitis, fevers

• PMH: HIV/AIDS, diverticulitis, OSA (CPAP HS), GERD, HLD

• Status: Full code

• Neuro: A&O x4

• Resp: RA

• CV: Stable

• GI: Abdominal pain, suspected C. diff; contact isolation

• Mobility: Ambulatory

• Access: Not specified

• Pain/Tx: Morphine q3h, Dilaudid q4h, Tylenol q6h

• Plan: Continue isolation, pain management, monitor for C. diff results

Patient: 83F

• Dx: Symptomatic anemia, chest pain

• PMH: HLD, HTN, CAD w/ stents, Afib, DM

• Status: DNR

• Neuro: A&O x4, occasional confusion

• Resp: RA

• CV: Stable

• GI: Persistent diarrhea; s/p EGD; NPO → advanced to clears

• Heme: s/p 2U PRBC (Hgb improved from 4.6 → 8.7 on 10/18)

• Mobility: Bedrest, SBA x1

• Access: #22 L forearm, difficult stick

• Diet: Clears

• Meds: Ferrous gluconate, Protonix, Miralax, sliding scale insulin

• Plan: Monitor diarrhea, repeat H/H, supportive care

Patient: 83F

• Dx: LLL pneumonia

• PMH: CVA, HTN, DVT, CKD, CHF, COPD, IVC filter

• Status: Full

• Resp: 2L NC, CPAP at bedside

• CV: Stable

• Mobility: Bedrest at baseline

• Access: #20 Right AC

• Meds: Prednisone, Isosorbide, Metoprolol, Lasix, Zyrtec, Lipitor, Nystatin powder, Symbicort, ASA

• Tests: CT chest, bedside CXR today

• Plan: Discharge canceled today, continue medical management

• Patient: 34M

• Dx: Sepsis

• PMH: Quadriplegia, respiratory failure, brain injury, cardiac arrest, anemia

• Status: Full code

• Neuro: Nonverbal baseline

• Resp: Trached & capped, continuous monitoring, tachycardic on tele

• Isolation: MDRO precautions

• GI: NPO; PEG tube feeds (2 cal @ 55/hr)

• GU: Chronic Foley

• Access: R midline

• Other: Bilateral wrist mitten restraints (non-violent)

• Plan: Continue PEG feeds, monitor sepsis parameters, supportive care.