Pt. name:Pinkie Tuskaderro                              Admitting Physician: Dr Young blood                
Age: 58                                                DOB: 02-05-1953                                    Bed: E145
Admitting diagnosis: bowel obstruction
Pt. ID # 777277                                                 Med Rec #: 7778277  
Wt. lbs: 143     kg:   65                       Ht.:5'7'                                     Race: C
Major Support: family                                                                        Religion: Christian
Immunizations: n/a
Allergies: NKDA
Physician Progress Notes
Nursing Assessment
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Physician Orders

date/time 
orders
 
8/4/2011 
Diagnosis: Small bowel obstruction
Admit to Medical floor for Dr. D. Ward 
      
LAB:     CBC, CMP stat on arrival to floor; call results to MD
         UA on arrival; may place foley if pt unable to void. 
      
Dx Exams:KUB of abdomen and pelvis 
         CT w/out contrast abdomen and pelvis; have radiology call results to MD. 
         EKG.
 
      
NPO
Place NG tube on arrival to floor
IVF: D5 1/2 NS at 120ml/hr
Phenergan 12.5mg-25mg IVP q 4-6hrs PRN for nausea
Protonix 40 mg IV q 24 hrs
Flagyl 500 mg IVPB q 6 hrs

      
Consult with gastroenterologies and surgeon    on call in AM.

      

Electronic signature:  Dr. D. Youngblood, 8/4/2011; 0200