Pt. name:  Ricky Radarsky                            Admitting Physician:   Bruce Jones           
Age:
49                                               DOB: 09/21/61                               Bed: 243
Admitting diagnosis:
CAP
Pt. ID # 542768
                                                Med Rec #:  78543
Wt. lbs: 171    kg: 77.7                    Ht.: 6 ft                                   Race: C
Major Support:
 Family                                                                     Religion: Christian
Immunizations:
NA
Allergies:
nkda

 

Physician Orders
date/time

orders

10/1/2010
1548

Admit to medical unit, diagnosis pneumonia
condition fair
nkda
VS q4 hr, I&O
BR with BRP
Dietary consult - diet as tolerated
Blood Cultures x 2
CBC
BMP
Sputum - Gram stain, C&S
UA
CXR - PA/Lat
EKG
SpO2 q shift
O2 to keep O2 sat greater than 90% per O2 protocal
Xopenex 1.25mg by HHN q4 hrs PRN difficulty breathing, wheezing, or desaturation
Azithromycin 500 mg IV q24 hrs
ceftriaxone 1 gm IV q24 hrs
Zofran 4mg IV q6 hrs PRN nausea or vomiting
SL - routine and prn flushes
Resume home med - Protonix 40 mg PO daily
Tylenol gr. X q4 hrs prn temp. > 101
guafenesin 2 teaspoons q4 hrs PRN cough

10/1/2010
1654

DVT Prophylaxis Protocal - Lovenox 30mg SQ q24 hrs
PATIENT CATEGORY / RISK FACTORS:
Patient is >40 years old & no additional risk factor - Mod risk
CBC, PT/INR, PTT before starting

Influenza vaccine: per Influenza Vaccination Screening & Administration Protocol
Pneumonia vaccine: per Pneumococcal Vaccination Screening & Administration Protocol