Pt. name:  Dale Mayman                        Admitting Physician:   Dr. S Phillips       
Age:
51                                           DOB: 11/13/xx                             Bed: ER Bed 2
Admitting diagnosis:
Confusion bleeding gums
Pt. ID # 542768
                                                Med Rec #:  78543
Wt. lbs: 172  kg: 78                 Ht.: 71 inches                                 Race:Caucasian
Major Support:
 Wife                                                                      Religion:
Not stated

Immunizations: current
Allergies:
Ace inhibitors (angioedema)

 

Nursing Map of Care
Complete Patient Assessment

History and Physical

Name:  Dale Mayman                    Gender:  Male                   Age: 51                                 DOB:  11/13/xx
Weight: 78 kg (172 lbs)                   Height: 71 inches              Race: Caucasian                Religion: Not stated
Major Support:  Wife
Allergies:  Ace inhibitors (angioedema)
Social History:  Mr. Mayman is just married again, having been divorced twice.  He is now disabled, but before that he worked as a truck driver.
Prior medical history:
Dale Mayman has a known chronic liver disease secondary to alcoholic cirrhosis. He has abused alcohol for over 25 years (6 – 8 beers per day).  Mr. Mayman has also a history of hypertension.
Recent medical history:
Dale Mayman has a chronic liver disease managed with salt restriction and diuretic therapy.  Neither Mr. Mayman nor his wife can recall if he has received a paracentesis before.  Wife has told the PCP upon admission that Mr. Mayman has been restless and somewhat more confused the last four days.
Time:
Dale Mayman is a 51-year-old male who went to the ER yesterday due to bleeding from gums, restlessness, and confusion.  Lab completed: CMP, PT/INR, ammonia, CBC, Blood cultures x 2, UA and urine culture, sputum culture, serum ETOH, urine tox screen.
He was sent home on home health care for assist with medication, diet, and monitoring.  He received a dose of Lactulose and had a paracentesis performed in the ER prior to discharge. The paracentesis revealed a spontaneous bacterial peritonitis.  He appeared jaundiced with mild ascites despite the paracentesis.   During the night the wife reports that the patient was slightly confused and had 2 bowel movements. His dressing on his abdomen from the paracentesis remains dry and intact.  His IV saline lock remains in his right forearm. IV site is without redness, swelling, or pain. Patient has been less cooperative with following his discharge instructions and is refusing to take any more lactulose. Vital signs:  RR: 22, HR: 88, BP:  130/83 Temp: 100.3