Progress Notes All Notes continued HYDROmorphone CLINICIAN BOLUS PCA Standard

Progress notes all notes continued hydromorphone

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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
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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.
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  • Spring '14
  • CherylA.Wenger
  • Trigraph, Mark Erickson, Brien M. Rabenhorst, •HYDROmorphone, •ondansetron

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