No Known Drug Allergies/Tree Nuts(Hives)
heart failure, hypertension, ovarian cyst
hysterectomy at age 50, wisdom teeth removal at age 20
widowed, retired. Denies tobacco, etoh, and substance use
| Time | Provider | Notes |
|---|---|---|
| 0830 | Michael Stark M.D. | AAOx3, in bed. Patient started having diarrhea 3 days ago with associated loss of appetite and nausea. Denies vomiting. Patient ate at a roadside diner while traveling about 5 days ago. Patient had a large salad with salmon. Patient felt queasy several hours after the meal and developed watery stools 2 days later. She thought the diarrhea would pass, but became worried today when they continue to have multiple episodes of liquid diarrhea and things have not improved. She also felt increasingly fatigued with palpitations. Monitor patient for dehydration. Evaluate for foodborne pathogen exposure. |
| Time | 0800 | |
|---|---|---|
| Heart Rate | 126 bpm | |
| Blood Pressure | 92/58 mmHg | |
| Respiratory Rate | 18 breaths/min | |
| Temperature | 100.5 F | |
| Pulse Oximetry | 98% | |
| Oxygen in Liters | Room Air | |
| Pain | 6/10 |