Progress notes all notes continued hydromorphone

Progress Notes - All Notes (continued)
HYDROmorphone CLINICIAN BOLUS (PCA - Standard)
ondansetron (conc: 2mg/mL) injectable 2 mg
ORTHOPAEDICS DAILY PROGRESS NOTE
DATE OF SERVICE:
POST OP DAY:
2
SURGICAL PROCEDURE : Primary VEPTR insertion Ribs 4,5 to L2,3
SUBJECTIVE:
Pt did much better overnight. Pain is better controlled, now on 3L, O2, and pain is better
controlled. Pt sat up with PT yesterday.
OBJECTIVE:
Current Medications:
Current Facility-Administered Medications
Medication
tranexamic acid (conc: 100mg/mL) injection 1,005 mg
tranexamic acid 1,250 mg in NS (0.9% sodium chloride) 25 mL
acetaminophen (conc: 160mg/5mL) oral suspension 302 mg
HYDROmorphone (conc: 2mg/mL) injectable 0.1-0.3 mg
oxyCODONE (conc: 1mg/mL) oral solution 2 mg
ondansetron (conc: 2mg/mL) injectable 2 mg
bacitracin injection
D5W-1/2NS + KCl 20 mEq/L 1,000 mL
ketorolac (conc: 30mg/mL) injectable 10.1 mg
polyethylene glycol 3350 oral powder 8.5 g
acetaminophen (conc: 160mg/5mL) oral suspension 240 mg
acetaminophen (conc: 160mg/5mL) oral suspension 240 mg
ibuprofen (conc: 100mg/5mL) oral suspension 200 mg
diazepam (conc: 1mg/mL) oral solution 2.01 mg
oxyCODONE (conc: 1mg/mL) oral solution 2 mg
clindamycin in D5W (dextrose 5%) (conc: 18 mg/mL) 201 mg
bisacodyl (MAGIC BULLET) rectal suppository 5 mg
fleet pediatric enema 66 mL
sennosides (conc: 8.8mg/5mL) oral syrup 10 mL
docusate sodium (conc: 50mg/5mL) oral solution 100 mg
ondansetron (conc: 4mg/5mL) oral solution 2 mg
ranitidine 20.1 mg in NS (0.9% sodium chloride) 10.05 mL
ranitidine (conc: 75mg/5mL) oral syrup 37.5 mg
naloxone (conc: 400mcg/mL) injectable 20.1 mcg
HYDROmorphone 100 mcg/mL *PCA - Standard*
HYDROmorphone CONTINUOUS RATE (PCA - Standard)
HYDROmorphone PCA DOSE (PCA - Standard)
(MR # Printed by [103311] at 10/11/13 10:09 AM Page 18
Author Type: Fellow
Filed: 9:28 AM Note Time: 9:25 AM Cosigner: Erickson, Mark A. at 7:51
PM
Electronically signed by Ries, Regina M. at 6:07 PM
Progress Notes signed by Rabenhorst, Brien M. at 9:28 AM
Author: Rabenhorst, Brien M. Service: Surgery-Orthopedics

IP Encounter Report MRN:
DOB: Sex: M
Adm: D/C:
Progress Notes - All Notes (continued)
HYDROmorphone CLINICIAN BOLUS (PCA - Standard)
ondansetron (conc: 2mg/mL) injectable 2 mg
Oxygen: supplemental oxygen
Drain Output:
Intake/Output Summary (Last 24 hours) at 0926
Last data filed at 0600
Gross per 24 hour
Intake 1355 ml
Output 975 ml
Net 380 ml
PHYSICAL EXAM:
Vital Signs : BP 104/80 | Pulse 130 | Temp 36.4 | Resp 24 | Ht 113 cm | Wt 20.1 kg | SpO2 98%
General:
appears healthy, well developed, well-nourished and in no acute distress
HEENT: Normocepahlic and atraumatic
Neck: there is full active range of motion
Chest: no increased work of breathing
Cardiac:
peripheral pulses strong and equal
Abdomen: soft, non-tender
Skin: pink, warm, well perfused, no rashes
Musculoskeletal:
Upper extremities: full and painless active range of motion - shoulder, elbow, forearm, wrist, hand,
symetrical and normal muscle strength and skin and vascular exam normal with no evidence of infection
Lower extremities:
BLE: +TA/GS/EHL/FHL, sensation intact to light touch throughout feet,brisk capillary
refill
Data/Diagnostics Studies
Past 24 hour labs:
none
No new studies in last 24 hours.